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MEDICAL    SCHOOL 


BERTRAM  STONE,  M.D 


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AN     ATLAS 


OF 


—  hoc  mihi  juris 
Cum  venia  dabis." 

HOR.  SAT.,  I,  4. 


AN    ATLAS 


or 


TOPOGRAPHICAL    ANATOMY 


AFTER  PLANE  SECTIONS  OF  FROZEN  BODIES 


BY 


WILHELM   BEAUNE 

PROFESSOR    OF    ANATOMY    IN    THE    UNIVERSITY    OF    LEIPZIG 


WITH    FORTY-SIX    WOODCUTS    IN    THE    TEXT 


TRANSLATED    BY 

EDWABD    BELLAMY,    F.B.C.S. 

SENIOR   ASSISTANT   SURGEON   TO   THE   CHARING   CROSS    HOSPITAL;     LECTURER   ON   ANATOMY   AND   TEACHER   OF 

OPERATIVE    SURGERY   IN   ITS    SCHOOL;     PROFESSOR    OF   ANATOMY  AS   APPLIED    TO    THE    FINE 

ARTS   IN   THE   SCIENCE   AND   ART   DEPARTMENT,   SOUTH    KENSINGTON 


PHILADELPHIA 

LINDSAY    AND     BLAKISTON 
1877 


TO 

CHRISTOPHER    HEATH,    F.R.C.S. 

SUEGEON  TO  UNIVERSITY  COLLEGE  HOSPITAL  AND  HOLME  PEOFESSOR  OF  CLINICAL  SUEGEET 

IN   UNIVEBSITY   COLLEGE 

THE 

ENGLISH   EDITION   OF  THIS   WORK 

IS    INSCEIBED 

IN  RECOGNITION  OF  THE  ESTIMATION  IN  WHICH  HIS  PROFESSIONAL 
SKILL  IS,  FROM  PERSONAL  EXPERIENCE,  HELD 


THE     TRANSLATOR 


AUTHOE'S    PEEFACE 


THE  accompanying  plates,  representing  plane  sections  of  the  human 
body,  are  reproduced  on  a  smaller  scale  from  my  large  atlas,  in  which  the 
figures  are  the  size  of  nature ;  and  are  intended  to  assist  in  extending 
and  increasing  the  knowledge  of  the  human  form,  and  of  the  position  of 
the  different  organs  to  each  other.  The  necessity  for  such  plates  for 
the  clinic  has  repeatedly  been  expressed,  and  especially  for  military 
surgery.  It  has  been  emphatically  stated  on  all  sides  that  the  sections 
of  the  thorax  and  abdomen  are  indispensable  for  diagnosis,  and  that  the 
examination  of  my  plates  has  been  of  substantial  assistance  in  judging 
correctly  the  direction  of  a  gunshot  wound.  Consequently  when  the 
question  arose  as  to  preparing  another  edition  of  the  large  coloured  atlas, 
it  seemed  advisable  at  the  same  time  to  arrange  a  smaller  one,  which 
could  be  made  accessible  to  a  wider  circle  of  readers.  The  plates  of  the 
large  atlas  are  faithfully  reproduced  by  photography.  Some  few  plates 
have  been  omitted  as  of  subordinate  interest.  The  text  remains  unaltered, 
with  the  exception  of  a  few  additions. 

As  each  plate  has  its  special  text  appended,  a  detailed  use  of  the 
atlas  is  rendered  possible ;  and,  as  circumstances  require,  recapitulations 
are  introduced  for  the  elucidation  of  individual  plates.  In  like  manner 
the  precise  data  relating  to  the  structure  of  the  individual  subjects  are 
retained  and  repeated  in  connection  with  the  plates,  in  order  that  the 
observer,  by  examining  them,  may  avoid  mistakes  on  the  living  body. 


Vlll 


It  will  be  perceived  that  the  work  is  not  intended  to  be  a  text-book  of 
topographical  anatomy,  but  an  atlas,  which  may  take  its  place  amongst 
manuals  on  the  subject,  as  an  illustrated  means  of  assistance. 

WILH.  BRAUNE. 


I. K I  I'M-;  ; 

November,  1874. 


THE  great  success  of  Professor  Braune's  Atlas  abroad  has  induced 
him  to  publish  a  smaller  edition  of  his  large  work,  with  photographs  of 
the  original  plates  reduced  to  half-scale.  It  has  been  considered  advisable 
to  take  advantage  of  this  to  reproduce  the  volume  in  English. 

The  immense  expense  of  producing  such  plates  and  the  persistent  dearth 
of  material  have,  in  all  probability,  .been  the  cause  why  no  original  English 
work  on  topographical  anatomy  has  as  yet  been  placed  within  the  reach  of 
the  generality  of  students. 

It  is,  I  think,  generally  admitted  that  there  is  a  want  in  this  country  of 
a  good  text-book  on  applied  anatomy,  and  not  a  mere  handbook,  but  such 
a  work  as  might  take  its  place  with  those  of  Richet,  Hyrtl,  or  Luschka. 
By  means  of  the  sections  found  in  this  Atlas  the  exact  position  and  rela- 
tions of  the  structures  which  must  be  divided  or  avoided  in  the  course 
of  an  operation  are  indicated ;  and  the  track  of  a  bullet  or  punctured 
wound  suggested.  At  the  same  time  they  afford  an  absolutely  correct 
representation  of  the  intimate  relations  of  the  viscera  of  the  thorax  and 
abdomen. 

I  cannot  help  thinking  that  the  work  may  be  of  great  value  to  artists, 
as  demonstrating  the  exact  position  of  the  bones  to  the  muscles  and 
indicating  the  contours  of  the  body. 

I  have  endeavoured  to  avoid  a  slavish  translation  of  the  text,  and  to 


x  TRANSLATOR'S  PREFACE 

reproduce  the  author's  meaning  in  readable  English,  without  interfering 
more  than  was  absolutely  necessary  with  the  original  construction  of 
the  sentences.  I  have  taken  the  liberty  of  omitting  some  irrelevant 
matter,  such  as  the  repetition  of  methods  of  preparation,  &c.,  which  would 
be  unnecessary  and  burdensome  to  the  English  student.  In  the  text  to 
Plates  XXIX  (A,  B),  XXX  and  XXXI,  finding  that  the  description  of  the 
section  of  the  foetus  referred  to  the  author's  large  work  more  particularly 
and  was  not  in  any  way  illustrated  by  the  present  series  of  plates,  I  omitted 
it.  I  trust  that  Professor  Braune  will  not  consider  that  I  have  in  any  way 
mutilated  his  text  or  impaired  its  utility. 

I  cannot  of  course  hold  myself  answerable  for  the  opinions  of  the 
author  in  his  surgical  and  medical '  comments,  but  have  simply  rendered ' 
them  as  I  trust  he  intends  them  to  be  understood.  I  have  reduced  the 
measurements  to  their  equivalent  English  notation  (with  the  exception 
of  the  long  table  on  page  155),  on  the  advice  of  friends,  although  I 
consider  that  it  would  have  been,  in  some  respects,  preferable  to  have 
retained  the  metric  scale. 

I  must  express  my  warmest  thanks  to  my  friends,  Mr.  Edmund  B. 
Owen,  F.R.C.S.,  Lecturer  on  Anatomy  in  St.  Mary's  Hospital,  and  Dr. 
J.  Mitchell  Bruce,  M.A.,  Assistant-Physician  to  Charing  Cross  Hospital, 
for  their  kindness  in  revising  the  proof-sheets,  and  for  many  valuable 
hints. 


EDWARD   BELLAMY. 


MARGARET  STREET,  CAVENDISH  SQUARE  ; 
October,  1876. 


CONTENTS 


PLATE  PAGE 

I  (A,  B).    Sagittal  section  of  the  body  of  a  male,  set.  21                          .  .               .1 

II  (A,  B).    Sagittal  section  of  the  body  of  a  female,  set.  25        .                .  .               .17 

III.     Obliquely  transverse  section  of  the  head,  passing  through  the  eyeballs ;  female,  set.  16      38 

IY.     Transverse  section  through  the  internal  ear ;  male           .                .  .                .44 

Y.  Transverse  section  through  the  head;  male.  Fig.  1.  At  the  level  of  the  teeth. 
Fig.  2.  At  the  level  of  the  upper  edge  of  the  thyroid  cartilage  and  fifth  cervical 
vertebra  .  .  .  .  .  .  .  .49 

YI.     Transverse  section  of  the  same  body  through  the  neck  at  the  level  of  the  cricoid 

cartilage  and  sixth  cervical  vertebra  .  .  .  .  .56 

VII.     Transverse  section  of  the  same  body  through  the  neck  and  shoulders  at  the  level  of 

the  seventh  cervical  vertebra         .  .  .  .  .  .64 

VIII.  Transverse  section  of  the  same  body  through  the  apices  of  the  lungs  and  shoulder- 
joints  at  the  level  of  the  first  dorsal  vertebra  .  .  .  .68 

IX.     Transverse  section  of  the  thorax  of  a  male  at  the  level  of  the  third  dorsal  vertebra    .       75 

X.     Transverse  section  of  the  same  body  at  the  level  of  the  arch  of  the  aorta  and  fourth 

dorsal  vertebra  .  .  .  .  .  .  .83 

XI.    Transverse  section  of  the  same  body  at  the  level  of  the  bulbus  aortse  and  sixth  dorsal 

vertebra  .  .  .  .  .  .  .  .91 

XII.     Transverse  section  of  the  same  body  at  the  level  of  the  mitral  valve  and  eighth  dorsal 

vertebra  .  .  .  .  .  .  .  .99 

XIII.  Transverse  section  of  the  same  body  at  the  level  of  the  apex  of  the  heart  and  ninth 

dorsal  vertebra  .......     105 

XIV.  Transverse  section  of  the  same  body  through  the  liver,  stomach,  and  spleen,  at  the 

level  of  the  eleventh  dorsal  vertebra  .....     115 

XV.     Transverse  section  of  the  same  body  through  the  pancreas  and  kidneys  at  the  level 

of  the  first  lumbar  vertebra  ......     122 

XVI.  Transverse  section  of  the  same  body  through  the  transverse  colon  at  the  level  of  the 
umbilicus  and  intervertebral  space  between  the  third  and  fourth  lumbar 
vertebra  .  .  .  •  .128 


Xll 


CONTENTS 


PLATE  PAGE 

XVII.    Transverse  section  of  the  same  body  through  the  pelvis  at  the  level  of  the  upper 


portion  of  the  head  of  the  thigh  bone       . 

XVIII.  Transverse  section  through  the  pelvis  of  a  male,  set.  25,  through  the  lower  portion 
of  the  head  of  the  thigh  bone  .... 

XIX.  Fig.  1.  Vertical  section  of  an  injected  knee-joint;  female,  middle  age.  Fig.  2. 
Vertical  section  through  the  right  foot,  close  to  its  inner  edge,  from  the  same 
body  .... 

XX.  Fig.  1.  Transverse  section  through  the  upper  portion  of  the  thigh,  parallel  with 
and  close  to  Poupart's  ligament  (same  body  as  Plate  I).  Fig.  2.  Transverse 
section  through  the  left  thigh  of  the  same  body  close  to  the  trochanter  minor  . 

XXI.  Fig.  1.  Transverse  section  of  the  left  thigh,  just  below  the  middle  third,  from  the 
same  body.  Fig.  2.  Transverse  section  of  the  left  thigh  through  the  middle, 
from  the  same  body  ....... 

XXII.  Fig.  1.  Transverse  section  of  the  lower  third  of  the  left  thigh  (male,  middle  age). 
Fig.  2.  Transverse  section  through  the  left  knee  of  the  same  body  . 

XXIII.  Fig.  1.  Transverse  section  through  the  upper  third  of  the  left  leg  of  the  same  body. 

Fig.  2.  Transverse  section  through  the  middle  of  the  left  leg  of  the  same  body 

XXIV.  Fig.  1.  Transverse  section  through  the  lower  third  of  the  left  leg  of  the  the  same 

body.     Fig.  2.  Transverse  section  through  the  malleoli  of  the  same   . 

XXV.     Frontal  section  through  the  thorax ;  male     ..... 

XXVI.  Fig.  1.  Vertical  section  through  the  right  elbow-joint ;  female.  Fig.  2.  Vertical 
section  through  the  hand  and  third  finger  of  the  same  body 

XXVII.  Figs.  1 — 4.  Transverse  section  through  the  left  arm,  through  the  middle  of  the 
lower  third  of  the  humerus,  through  the  trochlea,  and  head  of  the  radius ; 
male,  set.  40 . 

XXVIII.     Figs.  1 — 4.  Transverse  section  through  the  left  fore-arm  of  the  same,  the  upper 
middle  and  lower  thirds,  and  wrist -joint  .... 


135 


142 


149 


157 


161 


163 


Tab.I.v 


Tab.  In. 


TOPOGBAPHICAL    ANATOMY 


PLATE    I  (A,B) 

THE  accompanying  plate  was  taken  from  the  body  of  a  powerful, 
well-built,  perfectly  normal  man,  aged  21,  who  had  hanged  himself. 
The  organs  exhibited  no  pathological  irregularities.  The  body,  which 
was  brought  in  unfrozen,  was  placed  on  a  horizontal  board,  without  any 
special  support  for  the  head,  and  it  was  only  by  laying  it  down  that 
provision  could  be  made  for  the  limbs  lying  as  symmetrically  as 
possible  with  regard  to  the  mesial  line.  In  this  position  the  subject  lay 
untouched  in  the  open  air,  and  at  a  temperature  of  about  50°  F.,  for 
fourteen  days.  At  the  end  of  this  time  the  process  of  freezing  was  com- 
menced and  completed.  The  mesial  line  of  the  body  was  next  accurately 
marked  out  anteriorly  and  posteriorly  with  a  black  line,  and  the  section 
carefully  performed  by  means  of  a  broad,  fine-edged  saw,  much  in  the  same 
way  as  two  workmen  would  saw  the  trunk  of  a  tree.  After  cleansing  the 
surface,  the  right  half  of  the  body  showed  that  a  most  successful  section 
had  been  made.  In  the  brain  the  fifth  ventricle  had  been  traversed ;  in  the 
thorax  the  mediastinum,  so  that  neither  of  the  pleurse  was  opened ;  and  in 
the  pelvis  the  upper  third  of  the  urethra.  The  tracing  was  then  taken  from 
the  frozen  surface.  Where  the  course  of  the  section  had  not  exactly  kept 
the  mesial  plane,  I  improved  the  preparation  subsequently  in  such  places 
as  the  nature  of  the  case  required.  Thus,  a  thin  slice  of  the  cerebellum 
was  removed  by  means  of  a  razor,  and  the  entire  course  of  the  aquseductus 
Sylvii  exposed  down  to  the  fourth  ventricle,  with  the  penile  portion  of  the 
urethra  and  the  anus  where  not  opened  in  the  middle  line.  The  plane  of 

1 


2  PLATE   I 

the  section  passed  close  against  the  contracted  anus,  which  was  opened  after 
the  body  had  thawed ;  this  accounts  for  the  apparent  size  of  this  passage. 
In  sections  which  pass  through  the  anus  in  the  frozen  condition  of  the  body 
the  anterior  wall  lies  nearer  to  the  posterior,  not,  however,  so  close  that 
complete  apposition  is  permitted. 

It  is  also  to  be  observed  that  the  details  in  these  plates  were  worked 
out  from  fresh  preparations,  in  order  to  produce  as  useful  a  result 
as  possible;  due  notice  will  be  taken  of  these  details  in  the  proper 
places. 

With  regard  to  the  structures  entering  into  the  formation  of  the  skeleton 
as  seen  in  the  section,  the  vertebral  column  holds  the  chief  place.  The 
section  has  been  so  directed  that  it  passes  almost  through  the  middle  line 
of  the  bodies  of  the  vertebra;  and  that  the  arches,  on  the  other  hand, 
as  is  clear  in  the  dorsal  region,  are  divided  somewhat  to  the  right  of  the 
middle  line. 

An  examination  of  the  individual  portions  of  the  vertebra  shows  the 
spinal  column  to  be  quite  normal.  No  deformity  at  all  was  to  be  found 
in  the  bodies  of  the  vertebra  (as  is  so  frequently  the  case  in  aged  indi- 
viduals), but,  on  the  other  hand,  a  great  amount  of  mobility  in  the  parts 
was  met  with,  characteristic  of  a  young  and  actively  built  person.  The 
sacrum  was  devoid  of  any  irregularity,  and  had  a  perfect  and  uniform  curve. 
That  only  two  portions  of  the  coccyx  are  to  be  seen  in  the  plate  is 
owing  to  a  variation  which  this  part  of  the  skeleton  presents,  and  is  not 
remarkable. 

On  examination  of  the  vertebral  column  in  general,  its  considerable 
amount  of  curvature  is  first  of  all  worthy  of  notice. 

One  would  clearly  expect  that  in  the  horizontal  position  a  flatter  curve 
would  be  met  with,  as  the  spine,  when  examined  in  preparations  after  the 
removal  of  the  thoracic  wall  and  viscera,  shows  a  much  flatter  arc  in  the 
two  halves  of  the  body. 

Parow,  however,  has  proved  (Yirchow's  '  Archiv/  Bd.  xxxi,  p.  108,  &c.) 
that  the  removal  of  the  viscera  of  the  thorax  causes  a  great  increase  in  the 
flattening  of  the  spinal  column.  One  needs  only  to  compare  the  method 
which  was  stated  by  him  after  the  measurement  of  an  isolated  vertebra,  and 


PLATE   I  3 

is  figured  a  a  0,  PI.  Y,  fig.  4,  with  that  given  by  E.  "Weber  ('Mechanik 
der  menschlichen  G-ehwerkzeuge ')  and  with  mine,  in  order  to  see  at  once 
the  great  difference. 

If  the  plate  before  us  be  compared  with  that  which  Pirogoff  ('  Anatome 
Topographica,'  1859,  fasc.  I,  A,  Tab.  10,  11),  made  from  a  body  which  was 
also  frozen  in  the  horizontal  position,  and  then  sectioned,  it  will  be  found 
that  the  curvatures  are  nearly  exactly  the  same.  Both  differ,  however,  in 
this  respect  from  Weber's,  as  they  do  not  show  so  considerable  a  concavity 
in  the  dorsal  region.  As  Parow  found  by  his  observations  that  the  con- 
tents of  the  abdominal  cavity,  although  not  on  so  high  a  level  as  those  of  the 
thorax,  influenced  the  position  of  the  vertebra,  we  must  look  for  the  cause 
of  this  slight  difference  in  Weber's  preparation  in  the  previous  eventration. 
Although  Weber's  proposition  for  the  establishment  of  the  shape  of  the 
vertebral  column,  with  its  ligaments  and  discs,  is  excellent,  still  it  is  not 
thoroughly  applicable  to  all  vertebral  columns  in  connection  with  the  soft 
parts,  and  must,  therefore,  be  modified  according  to  circumstances. 

It  would  seem  now  worth  while,  in  the  vertebral  column  before  us,  to 
be  able  to  determine  what  this  variation  would  be  in  the  upright  position 
of  the  individual,  but,  unfortunately,  the  means  of  doing  so  are  impos- 
sible. 

If  any  series  of  representations  of  the  body  frozen  in  the  upright  posi- 
tion were  given,  no  advantage  would  be  obtained.  It  is  evident  that  it 
is  impracticable  to  keep  a  body  so  balanced,  and  in  such  equilibrium,  as 
the  muscles  are  capable  of  doing  during  life.  The  trunk  always  hangs 
over  to  one  side  to  such  an  extent  that  the  spine  partly  loses  its  original 
curvature  and  takes  a  semiflexure.  It  is  therefore  not  to  be  wondered  at 
that  the  figure  which  Pirogoff  (a  a  0,  Tab.  12)  gives,  taken  from  a  sub- 
ject frozen  in  the  upright  position,  exhibits  curves  having  flatter  arcs  than 
it  would  have  had  if  the  drawings  had  been  taken  from  one  frozen  in  the 
horizontal  position.  We  should  consequently  fall  into  a  great  error  if  we 
conclude  on  the  ground  of  Pirogoff 's  plate  that  in  the  living  individual, 
whilst  in  the  upright  position,  the  spine  has  a  lesser  curvature  than  when 
lying  down.  Parow,  indeed,  by  the  help  of  an  instrument  (Coordinaten- 
messer),  carried  out  a  number  of  observations  with  a  view  of  determining 


4  PLATE   I 

the  position  of  the  spinous  processes,  and  so  estimated  the  curvature  of  the 
spinal  column  on  the  living  body. 

But  valuable  as  these  observations  are  in  an  individual  case,  and  how- 
ever carefully  followed  out,  with  a  view  of  showing  that  each  variation  of  the 
attitude  and  balance  of  the  trunk  exercises  an  influence  on  the  position  of 
the  vertebrae,  it  appears  to  me  from  the  great  variation  in  the  forms  of  the 
spinous  processes,  that  no  absolute  rule  for  the  position  of  the  bodies  of  the 
vertebra  can  be  adduced,  more  especially  as  the  exact  definition  of  the  pro- 
montory still  renders  special  measurements  necessary.  Therefore  I  have, 
apart  from  this  consideration,  by  comparing  Parow's  curves  with  my  own 
plates,  estimated  the  alteration  which  the  spinal  column  presents  in  the 
upright  position.  An  exact  determination  of  the  line  of  gravity  of  the  spinal 
column  in  my  preparation  must  likewise  be  given  up.  It  is  not  possible  to 
estimate  with  certainty  how  this  line  passes  through  the  individual  sections 
of  the  vertebrae ;  and  such  definitions  can  only  be  undertaken  on  the  living 
body.  If  the  figure  be  placed  in  the  upright  position,  and  the  head  be  con- 
sidered as  held  forwards,  as  is  the  case  when  balanced  on  the  spine,  the 
excessive  convexity  in  the  cervical  region  becomes  somewhat  flattened,  and 
a  plumb-line  hanging  from  the  occipito-atloid  articulation  would  cut  approxi- 
mately the  vertebral  segments,  as  the  brothers  "Weber  have  shown.  It 
passes  downwards  close  behind  the  promontory  and  through  the  line  of 
junction'  of  the  heads  of  the  thigh  bones,  and  indeed  Parow  has  by  his 
measurements  fallen  back  on  this  proposition  of  Weber's. 

Also  it  is  shown  by  examining  the  inclination  of  the  pelvis  both  in  my 
plate  and  in  the  one  given  by  Pirogoff,  that  this  is  much  more  considerable 
than  Meyer  gives  it,  and  presents  nearly  the  same  angle  that  Weber  has 
determined  by  his  measurements.  The  line  joining  the  upper  border  of  the 
symphysis  pubis  with  the  promontory  of  the  sacrum  makes  an  angle  of  60° 
with  the  horizon. 

The  ligamentous  structures  belonging  to  the  vertebrae  are  represented 
in  the  plate  as  accurately  as  possible.  The  separate  portions  also,  such  as 
those  of  the  compound  ligamentous  apparatus  of  the  articulations  of  the 
cranium,  and  those  passing  down  on  the  anterior  and  posterior  surface  of  the 
bodies  of  the  vertebrae,  could  not  be  shown  in  any  detail  in  such  a  section. 


PLATE   I  5 

However,  at  the  odontoid  process  of  the  second  cervical  vertebra  the  trans- 
verse ligament,  with  its  articulation  on  the  anterior  cartilaginous  surface 
opposite  the  joint  fissure  between  the  atlas  and  odontoid  process,  is  clearly 
seen,  as  also  are  the  sharply  defined  elastic  ligamenta  subflava.  The  pos- 
terior occipito-atloid  ligaments  which  close  in  the  spinal  canal  between 
the  occiput,  atlas,  and  axis,  have  not  the  elastic  quality  of  the  ligamenta 
flava ;  they  are  but  slightly  distinct  from  the  overlying  cellular  tissue, 
and  therefore  not  particularly  prominent  in  the  drawing.  The  section  has 
passed  so  exactly  in  the  mesial  line,  that  in  the  neck  no  muscles  are  seen 
except  the  inter spinales,  and  one  in  the  lumbar  region  showing  through  its 
sheath.  In  the  dorsal  region,  on  the  other  hand,  where  the  section  had 
passed  somewhat  to  the  right  side,  the  tendon-like  structure  of  the 
multifidus  and  semispinalis  muscles  appear.  The  space  between  the 
spinous  processes  appears  in  other  places  filled  up  with  connective  tissue, 
which  belongs  to  the  interspinous  and  supraspinous  ligaments  derived 
from  the  ligamentum  nuchse  above.  At  the  inferior  end  of  the  spine  is 
seen  the  posterior  sacro-coccygeal  ligament,  which  closes  in  the  end  of  the 
spinal  canal,  and  attaches  itself  to  the  two  portions  of  the  coccyx  here 
shown.  The  intervertebral  discs  are  represented  exactly  as  they  appeared, 
and  their  fibrous  structure  and  pulpy  centre  are  clearly  shown.  It  appears 
that  in  the  most  movable  parts,  such  as  the  cervical  and  lumbar  regions, 
the  discs  have  an  unequable  thickness  before  and  behind,  whilst  those  in 
the  dorsal  region  are  of  an  even  thickness.  The  bodies  of  the  vertebrae  in 
the  region  of  the  thorax  are  of  different  depths,  anteriorly  and  posteriorly, 
and  consequently  influence  the  curvature  of  the  spine ;  and  it  is  shown  in 
the  region  of  the  neck  and  loins,  which  are  the  most  movable,  that  the 
intervertebral  discs  are  essentially  stronger  anteriorly  than  posteriorly, 
though  the  sides  of  their  respective  vertebrae  are  equally  deep. 

There  is  nothing  peculiar  to  remark  of  the  sternum  and  skull ;  they  are 
sufficiently  characterised  throughout.  The  spongy  portion  is  accurately 
shown  in  each  individual  bone  of  the  preparation.  Especial  care  was 
required  to  bring  each  portion  of  the  brain  clearly  under  notice.  Sections 
through  fresh  brains  were  used  in  order  that  the  drawing-in  of  the  parts 
within  the  dense  contours  should  be  made  clear  and  correct. 


6  PLATE   I 

Beneath  the  corpus  callosum  a  good  view  is  obtained  of  the  fornix. 
It  is  seen  as  it  passes  forward  and  downward  from  the  splenium,  and 
stopping  at  the  corpus  mammillare  which  lies  at  the  base  of  the  skull.  In 
front  of  this  last  lies  the  infundibulum,  which  leads  to  the  pituitary  body 
in  the  sella  turcica.  Still  further  forward  is  a  section  of  the  optic  chiasma. 
At  the  extremity  of  the  fornix  is  the  anterior  white  commissure.  Behind 
the  fornix  is  the  black  cleft  representing  the  foramen  of  Munro,  and  the 
inner  grey  lamina  of  the  optic  thalamus  with  the  grey  commissure.  From 
the  upper  white  lamina  of  this  some  fibres  are  to  be  seen  passing  to  the 
pineal  gland,  which  is  in  relation  inferiorly  with  the  posterior  white  com- 
missure and  the  corpora  quadrigemina.  Beneath  the  corpora  quadrigemina 
is  the  aquseductus  Sylvii  uniting  the  third  and  fourth  ventricles ;  the  anterior 
half  of  this  is  covered  by  the  corpora  quadrigemina,  the  posterior  half  being 
provided  with  grey  convolutions  above  from  the  valve  of  Vieussens.  The 
floor  of  the  fourth  ventricle  is  formed  of  grey  matter,  which  is  shown  to  be 
as  a  continuation  of  the  grey  nucleus  of  the  medulla.  This  becomes  clear 
from  the  departure  of  the  posterior  fibres  of  the  medulla  to  the  cerebellum. 

In  the  pons  Varolii  a  white  band  is  well  seen,  the  penetrating  fibres 
of  the  pyramid,  whilst  those  of  the  olivary  body  go  through  between  the 
pons  and  cerebellum.  Behind  the  pons  is  seen  a  portion  of  the  nucleus  of 
the  olivary  body  cut  through.  Between  the  several  portions  of  the  brain 
which  are  not  directly  in  apposition,  the  sites  of  the  great  subarachnoid 
spaces  are  seen.  One,  for  instance,  between  the  anterior  (here  upper) 
border  of  the  pons  and  the  corpus  mammillare,  and  a  second  between  the 
cerebellum,  the  medulla,  and  the  commencement  of  the  spinal  cord;  a 
third  between  the  posterior  part  of  the  corpus  callosum  and  the  cerebellum. 
The  investing  arachnoid,  which,  springing  across  from  one  portion  of  the 
brain  to  another,  so  forms  this  space,  cannot  be  reproduced  in  the  plate 
on  account  of  its  excessive  fineness.  Excepting  the  artery  of  the  corpus 
callosum,  which  passes  upwards  over  the  genu,  all  the  vessels  depicted  are 
veins. 

The  superior  longitudinal  sinus  is  laid  open  for  almost  its  entire  extent. 
The  inferior  longitudinal  sinus  on  the  lower  border  of  the  falx  is  only  to  be 
distinguished  by  the  blood  seen  through  its  walls.  Beneath  the  splenium  the 


PLATE   I  7 

vena  Galeni  magna  passes  upwards  in  order  to  empty  into  the  straight  sinus, 
of  which  only  a  small  portion  is  met  with  at  its  junction  with  the  lateral, 
whilst  the  thyroid  plexuses  of  the  third  and  fourth  ventricles  are  very 
evident  and  clearly  represented  in  the  plate.  The  dura  mater,  which  in 
the  cavity  of  the  skull  lies  close  down  upon  the  bone  and  on  the  foramen 
magnum,  and  is  connected  with  the  external  periosteum,  leaves  the  bony 
walls  in  the  spinal  canal  and  approaches  the  cord.  At  the  commencement 
of  the  cauda  equina  at  the  lumbar  vertebra  the  cord  can  (in  the  plate)  be  no 
longer  distinguished  from  the  dura  mater. 

It  will  be  observed  that  a  portion  of  the  septum  narium  has  been 
removed.  This  has  resulted  from  its  deflection  towards  the  left  side.  It 
was  not  caused  by  a  polypus.  I  amplified  the  defect  somewhat  in  order 
to  bring  the  relation  of  the  mucous  membrane  to  the  septum  narium  and 
the  two  upper  turbinated  bones  clearly  into  view.  Behind  the  septum  is 
seen  the  inferior  opening  of  the  Eustachian  tube.  It  follows  from  the 
relation  of  the  parts,  that  instruments  which  are  introduced  into  the  tube 
must  be  passed  along  the  floor  of  the  nares  in  order  to  preserve  the  neces- 
sary direction.  The  plate  shows  that  an  examination  of  the  opening  of 
the  Eustachian  tube  by  means  of  the  laryngoscope,  would  be  materially 
facilitated  by  drawing  the  velum  forward  and  upward.  The  relation  of  the 
uvula  to  the  glands  and  muscular  tissue  is  evident.  The  thickness  of 
the  velum  must  be  borne  in  mind  in.  the  operation  of  staphyloraphy.  One 
is  inclined  to  underrate  its  thickness,  and  thus  to  experience  difficulty  in 
freshening  the  edges  of  the  cleft. 

Mouth. — Before  the  freezing  of  the  subject  the  contents  of  the  stomach 
had  ascended  into  the  oesophagus,  and  partly  filled  up  the  cavity  of  the  mouth. 
After  removal  of  the  frozen  mass  its  tube  could  be  represented  in  the 
plate. 

It  can  be  seen  also  in  the  present  preparation  that  the  tongue  is  formed 
like  a  muscular  pestle,  which  can  thrust  hither  and  thither  the  contents  of 
the  cavity  of  the  mouth.  The  relation  between  the  tongue,  hyoid  bone,  and 
larynx  is  clearly  shown.  If  the  surgeon  desires  to  reach  the  larynx  easily, 
he  only  requires  to  draw  the  tongue  out  of  the  open  mouth,  and  can  then 
move  the  epiglottis  and  with  it  the  larynx  upwards  and  forwards.  The 


8  PLATE   I 

parts  of  the  hyoid  bone  and  the  neighbouring  organs,  which  are  here  shown, 
are  similar  to  those  represented  in  Pirogoff's  plate,  and  as  it  was  not  taken 
from  a  person  who  had  died  by  hanging,  they  may  be  regarded  as  normal. 

The  larynx  is  evenly  divided  in  the  mesial  plane,  and  offers  no  peculiari- 
ties for  consideration.  The  sections  of  the  cricoid  and  thyroid  cartilages, 
and  the  ventricle  of  Morgagni  between  them,  are  shown,  and,  on  account  of 
the  apposition  of  the  vocal  cords,  the  ventricle  appears  only  as  a  cleft.  The 
muscles  to  be  noticed  in  this  section  are,  on  the  posterior  wall  of  the  larynx, 
the  transverse  section  of  the  arytenoideus,  anteriorly,  between  the  cricoid 
and  thyroid  cartilages,  some  fibres  of  the  crico-thyroid  lying  close  in  the 
mesial  line,  and  above  a  portion  of  the  thyro-hyoid. 

The  ligaments  shown  are  the  glosso-epiglottic,  the  middle  thyro-hyoid, 
and  further  down  the  middle  crico-thyroid. 

The  section  of  the  neck  is  so  closely  in  the  mesial  plane  that  no 
vessels  are  seen,  except  a  vein  above  the  manubrium  sterni,  a  commu- 
nicating branch  uniting  two  subcutaneous  veins  of  ,the  neck.  It  lies 
enclosed  between  two  laminaD  of  fascia,  which  arise  from  the  splitting  of  the 
anterior  lamina  of  the  cervical  fascia.  Behind  this  lies  the  cut  edge  of  the 
sterno-thyroid  muscle.  Between  this  muscle  and  the  trachea  is  the  section 
of  the  middle  portion  of  the  thyroid  body  which  is  perfectly  normal  in  its 
relations.  The  plate  shows  the  direction  taken  by  the  knife  in  tracheotomy, 
and  the  importance  of  keeping  the  incision  exactly  in  the  middle  line  of  the 
neck. 

The  absence  of  arteries  in  the  middle  line,  as  is  almost  uniformly  the 
case,  shows  that  there  is  less  apprehension  of  danger  in  the  middle  line 
from  haemorrhage  than  laterally.  The  thyroidea  ima  artery  is  the  only 
one  which  would  be  met  with  in  such  a  plane,  and  this,  according  to 
Neubauer,  is  found  in  one  in  every  ten  bodies.  Since  this  vessel  takes  its 
origin  in  almost  all  cases  from  the  innomminate  its  distribution  must  be 
looked  for  somewhat  towards  the  right  of  the  middle  line.  As  the  trachea  lies 
further  distant  from  the  surface  of  the  body  as  it  descends,  the  operation  of 
tracheotomy  is  easier  of  performance  the  nearer  the  surgeon  approaches 
the  larynx,  consequently,  unless  there  are  contra-indications,  it  should 
be  performed  above  the  thyroid  body.  It  must  be  recollected  that  this 


PLATE   I  9 

gland  should  be  drawn  upwards  by  a  blunt  instrument  in  order  to  freely 
expose  the  upper  rings  of  the  trachea,  a  proceeding  unattended  with 
difficulty  owing  to  the  mobility  of  the  organ.  Should  the  operation  be 
performed  below  the  thyroid  body  there  is  a  considerable  depth  of  tissue  to 
get  through  before  reaching  the  trachea,  and,  moreover,  great  attention 
must  be  paid  to  the  position  of  the  vessels  of  the  neck.  The  position  of 
these  trunks  is  not  so  constant  that  any  general  rule  for  their  distance 
from  the  upper  edge  of  the  sternum  can  be  given. 

The  trachea,  which  in  this  preparation  divides  into  the  two  bronchi 
opposite  the  fourth  dorsal  vertebra,  has  tolerably  the  same  relations,  as 
shown  by  Luschka  (' Brustorgane,'  Tubingen,  1857).  It  appears,  however, 
from  sections  on  other  bodies  that  there  is  no  constant  point  of  division, 
and  different  authors  make  different  statements  on  this  matter.  Henle 
('  Anatomic, '  1866,  Bd.  ii,  p.  26  A),  describes  it  as  opposite  the  fifth  dorsal 
vertebra.  Pirogoff  in  his  plate  (Fasciculus  I  A,  tab.  14),  gives  it  as  high 
as  the  third. 

Thorax. — The  slight  depth  of  the  thorax  is  striking,  and  yet  one  can 
convince  oneself,  both  from  measurements  on  the  living  body  and  also 
from  Pirogoff's  plates,  that  there  is  in  this  case  no  abnormality.  The 
mediastinum  was  so  exactly  divided  by  the  section  that  neither  pleural  sac 
was  opened ;  whilst  of  the  lungs,  nothing  is  seen  but  a  small  strip  of  the 
right,  which,  covered  by  pleura,  is  shown  behind  the  body  of  the  sternum. 
In  Pirogoff's  plate  (Fasc.  I  A,  tab.  10,  44),  no  lung  is  to  be  seen,  by 
reason  of  the  considerable  breadth  of  the  mediastinum.  The  heart  was  so 
divided  that  only  a  flat  piece  of  the  arch  of  the  aorta  remained  in  the  right 
half  of  the  body,  whilst  the  root  of  the  pulmonary  artery  was  removed  with 
the  left  side,  its  right  branch  being  cut  through  The  superior  and 
inferior  venge  cavae  are  not  seen  at  all,  they  lie  deeply,  and  empty  themselves 
above  and  below  into  the  right  auricle,  so  that  their  point  of  entrance 
cannot  be  clearly  made  out.  If,  in  the  plate,  a  line  be  drawn  from  the 
anterior  border  of  the  septum  auriculorum  outwards  and  downwards,  the 
situation  of  these  deeply  lying  vessels  will  be  indicated.  The  large  cavity 
in  front  of  and  below  the  aorta  belongs  to  the  right  auricle,  the  larger 
portion  of  which  remained  on  the  right  half  of  the  body.  Its  cavity  extends 

2 


10  I'LATH    I 

upwards  toward  the  right  auricular  appendix,  of  which,  as  is  clear  !>v 
the  plate,  only  a  small  portton  nabbed  across  to  the  left  half  of  the  body 
posteriorly  towards  the  vertebrae,  and  somewhat  behind  the  left  auricle. 
A  large  portion  of  the  tricuspid  valve  has  been  removed  in  the  section. 

Only  a  small  portion  of  the  left  auricle  is  left,  and  this  is  seen  lying 

|,,|im,|    ,)„,    righi    aiiridr,  ;.(,.!    botWOei)    it    Mini    the   SpillSlI  ColuiMII.         Al.O.lt    t  Wo 

thirds  of  it  were  removed  with  the  left  half  of  the  body.  The  two  openings 
into  it  correspond  to  the  entrance  of  the  pulmonary  veins.  That  portion 
of  the  auricular  septum  containing  the  foramen  ovale  is  removed,  and  only 
a  small  portion  of  the  right  ventricle  is  noticed. 

Here  the  heart  was  cut  obliquely  near  its  upper  SHI -I';  ice,  and    there- 
fore its  muscular  tissue  and  fatty  layer  appear 

r  IO.  1. 

remarkably   clearly.      There   is  a  considerable 

amount  of  l':i.l.  <»ii  the  heart .  Tin-  muscular  struc- 
ture of  the  heart  and  Yahres,  however,  shows  no 
irregularity.  The  relation  of  the  pericardium  is 
clearly  shown.  The  accompanying  woodcut  ex- 
plains Uio  position  of  Mm  In-art,  wit  h  regard  to  t  ho 
mesial  lino  as  found  in  the  present  case,  from 
whence  result  the  rules  for  its  percussion.  It  will 

|M>  noliced  th.-it  tin-  relations  agl'e  exactly  with  those  {.riven  l»y  Luschka 
(loc.  fiit.t  tab.  iii). 

Tin-   entire    IniHli    of   tin-   (rsopliinnis    is    not^    distinctly    shown    liy    UK- 
in. 'di. in  section,  :is  in  ccrtnin  plan-s  tin-  lulu-  diverged  ronsiilrrnhly  from  the 

middle  lino.     In  this  preparation,  however,  on  account  of  the  contents  of 

tin-   slniuiidi  h;i\  in.r  i-iMnir.riinird  into    ii,    it    \v:is  so  distcndeil  that   lliejilano 
'  '      •    incl   it   ihi-oii^l,,,,,!   j|s  (.(,|,,-S(.. 

Abdomen. — It  can  be  seen  from  the  form  of  the  abdominal  walls,  that 
there  is  no  sinking-in  of  the  parietes,  but,  although  the  intestines  were 

moderately  di-t.-mled.  the  short   distance   of  the   iinibiliciis   1'roin  the  luinhar 

vortebrno  is  very  remarkable.     The  depth  of  the  abdomen  in  the  mesial  lino 
is,  indeed,  very  variable,  and  is  generally  represented  far  too  great. 

But  it  is  to  be  expressly  noticed  here  that,  the  condition  of  parts  seen  in 
the  present  drawing  is  not  precisely  the  same  as  in  the  living  body,  sinco  in 


PLATE   I  11 

the  dead  subject  the  lungs  are  in  the  position  of  fullest  expiration,  and  the 
diaphragm  reaches  its  highest  level ;  and  the  relation  of  the  intestines  with 
it,  the  distribution  of  the  blood,  and  the  arching  forward  of  the  abdomen, 
are  somewhat  altered.  Therefore,  with  reference  to  the  living  body,  the 
distance  of  the  vertebral  column  from  the  abdominal  walls  must  be  con- 
sidered as  somewhat  greater,  although  not  so  much  so  as  one  is  accustomed 
to  suppose.  From  this  relation  of  the  parietes  to  the  vertebrae,  the  possi- 
bility of  the  ready  compression  of  the  abdominal  aorta  may  be  inferred. 
Compression  becomes  the  easier  the  thinner  the  individual  and  the  less  full 
the  intestines.  Further,  it  is  evident  that  the  individual  should  lie  in  such 
a  position  that  the  lumbar  vertebras  be  bowed  as  much  forward  as  possible ; 
and  as  the  aorta  bifurcates  on  the  fourth  lumbar  vertebra,  the  pressure  should 
be  brought  to  bear  directly  on  the  navel. 

Intestines. — The  position  of  the  intestines  in  the  middle  line  should  be 
compared  repeatedly  with  other  sections  on  bodies  of  the  same  size.  It 
appeared  that  a  similar  figure  continually  obtained,  and  that,  with  exception 
of  some  of  the  coils  of  intestine,  the  stomach,  duodenum,  transverse  colon, 
iliac  flexure,  and  rectum,  when  in  an  equal  state  of  distension,  lay  pretty 
much  in  the  same  position.  In  one  case  the  stomach  was  found  in  such  an 
empty  and  contracted  condition  that  it  was  at  first  entirely  overlooked,  and 
when  it  was  found  the  little  finger  could  be  scarcely  pushed  into  its  cavity. 
On  examining  the  abdomen  it  appears  (and  more  so  than  in  other  regions) 
that  the  change  in  the  volume  of  individual  organs  as  well  as  their  mobility 
may  be  considerable  without  other  parts  having  essentially  to  suffer 
thereby.  For  fat  and  cellular  tissue  so  completely  surround  the  viscera 
that  no  empty  spaces  are  left,  and  thus  freedom  of  movement  and  com- 
pression are  permitted. 

The  section  of  the  liver  passes  through  the  left  lobe  near  the  lobulus 
Spigelii. 

The  pancreas  is  cut  through  near  its  head,  where  the  superior  mesenteric 
vein  approaches  the  liver.  The  other  part  of  it,  which  is  directed  from  the 
head  of  the  gland  to  the  middle  line  along  the  lower  horizontal  portion  of 
the  duodenum  (the  so-called  lesser  pancreas),  lies  behind  the  mesenteric 
vein,  so  that  it  looks  as  if  the  vein  passed  through  the  pancreas  itself. 


12  PLATE   I 

The  relations  of  the  peritoneum  are  represented  in  the  plate  as  they 
were  met  with  after  the  thawing  of  the  preparation ;  only,  for  the  sake  of 
clearness,  half  the  fat  of  the  greater  bag  of  the  peritoneum  has  been  taken 
away  and  the  layers  thereof  shown  somewhat  diagrammatically. 

A  vertical  section  in  the  middle  line  is  not  the  most  favorable  for 
showing  the  mutual  disposition  of  the  reflexions  of  the  peritoneum ;  an 
oblique  one  taken  outwards  from  the  foramen  of  Winslow,  through  the 
root  of  the  mesentery  to  the  iliac  flexure,  would  much  better  answer  the 
purpose.  Therefore,  in  the  accompanying  woodcut  I  have  given  a  diagram- 
matic representation,  which  will  at  least  make  clear  the  relation  of  the 
lesser  bag  to  the  other  portions  of  the  peritoneum.  The  individual  layers 
of  which  the  transverse  meso-colon  is  composed,  are  not  represented  in 
this  drawing  as  they  cannot  be  prepared  in  the  full-sized  body,  and  their 
diagrammatic  representation  would  only  complicate  the  drawing. 

On  the  relations  of  the  rectum  there  is  nothing  further  to  add.  The 
distance  of  the  peritoneal  sac  from  the  anus,  which  is  here  about  three 
inches,  is  to  me  noticed,  as  is  also  the  position  of  the  so-called  valves  of 
the  rectum.  Since  the  rectum  in  its  ascending  portion  courses  over  towards 
the  left  half  of  the  body,  there  is  only  a  flat  section  of  it  to  be  seen ;  in 
this  respect  my  plate  differs  from  those  of  Henle  and  Kohlrausch. 

The  representation  of  the  bladder  also  differs  from  that  given  by  the 
above-mentioned  authors,  it  was,  however,  accurately  drawn  from  the 
preparation.  The  bladder  was  completely  full  of  frozen  urine,  and  conse- 
quently there  was  no  sinking-in  of  its  upper  wall,  as  is  represented  in 
several  of  Pirogoff's  plates.  I  injected  the  bladder  with  tallow  as  soon  after 
death  as  possible,  partly  through  the  urethra  and  partly  through  the  ureter, 
both  in  the  vertical  and  horizontal  position,  in  order  to  compare  the  form 
and  situation  of  that  viscus.  A  section  in  the  mesial  plane  in  each  case 
showed  the  same  conditions  as  in  the  plate,  and,  with  reference  to  the 
flattening  of  the  upper  wall,  no  essential  difference  was  found  whether  the 
body  was  upright  or  lying  down. 

The  position  of  the  entrance  of  the  urethra  corresponds  with  Henle's  and 
Kohlrausch's  description,  though  no  absolute  similarity  need  be  expected. 
Langer  ('  Med.  Jahrb.  Wien.,'  1862,  3  Heft)  has  shown  that  many  consider- 


PLATE   I 

FIG.  2. 


13 


1.  Liver  cut  obliquely. 

2.  Lobulus  Spigelii. 

3.  Gall-bladder. 

4.  Stomach. 

*.  Foramen  of  Winslow. 

5.  Lesser  ornenturn. 


6.  Pancreas. 

7.  Transverse  colon. 

8.  Transverse  meso-colon. 

9.  Mesentery. 

10.  Jejunum. 

11.  Ileum. 


12.  Great  omentum. 

13.  Cavity  of  peritoneum. 

14.  Bladder. 

15.  Rectum. 

16.  Duodenum. 


14  PLATE   I 

able  variations  obtain  as  regards  this  matter.  Especial  care  was  expended 
on  that  envelope  of  the  bladder  which  forms  the  porta  vesicae  of  Retzius,  as 
this  is  not  very  clearly  shown  in  Henle  and  Kohlrausch.  It  is  shown  that 
from  the  termination  of  the  posterior  wall  of  the  sheath  of  the  rectus  (the  so- 
called  fold  of  Douglas)  two  laminae  of  fascia  take  their  origin,  and  then  pass 
down  close  to  one  another  between  the  rectus  and  the  peritoneum.  If  the 
bladder  be  only  moderately  distended,  as  in  this  case,  they  however  confine 
a  space  in  front  of  the  peritoneum,  which  is  taken  possession  of  by  the 
bladder  as  it  rises  upwards  during  distension.  The  anterior  lamina  passes 
downwards  as  a  thin  covering  upon  the  rectus  abdominis  and  lines  the 
space  between  the  bladder  and  the  symphysis  pubis ;  the  posterior  lamina 
passes  across  behind  the  urachus  on  to  the  bladder,  in  order  to  invest  it, 
and  to  join  the  prostatic  capsule  and  pelvic  fascia.  The  internal  vesical 
sphincter  is  clearly  seen  in  the  plate,  but,  on  the  other  hand,  the  external 
sphincter  is  not  completely  brought  into  view.  The  limits  of  the  prostate 
gland  are  clearly  defined,  also  the  parts  lying  in  front  of  the  urethra  are 
accurately  represented.  In  most  cases  the  muscular  fibres  and  gland  tissue 
are  not  exactly  made  out. 

In  front  of  the  prostate  is  the  middle  pubo-prostatic  ligament  with 
the  numerous  veins  which  form  the  plexus  venosus  of  Santorini.  Beneath 
it  is  some  muscular  tissue  which  has  not  been  completely  analysed. 
It  was  represented  as  it  stood,  and,  after  Henle,  is  comprehended  under 
the  name  of  deep  transverse  perineal  muscle;  it,  moreover,  corresponds 
with  Muller's  so-called  constrictor  of  the  membranous  urethra.  The  tri- 
angular ligament  of  the  urethra  (Colles),  which  lies  on  the  ligamentum 
arcuatum,  close  beneath  the  symphysis,  and  is  incorporated  with  the 
deep  transverse  perinei,  does  not  appear  very  clearly  defined  in  this 
section.  The  white  portions  on  the  anterior  border  of  the  above-mentioned 
muscular  mass  are  to  be  referred  to  this.  Vertical  sections  in  an 
antero-posterior  direction  are  not  adapted  for  the  demonstration  of  the 
pelvic  fasciae  and  muscles  j  those  made  across  the  axis  of  the  body  afford 
better  results. 

The  dorsal  vein  of  the  penis  and  the  suspensory  ligament  are  well 
shown. 


PLATE   I  15 

The  curvature  of  the  urethra  differs  somewhat  from  that  which  Kohl- 
rausch  describes  as  normal,  but  the  condition  here  represented  must  also 
be  regarded  as  such,  since  it  presents  no  pathological  irregularities  nor 
are  there  any  in  neighbouring  organs.  It  must  be  therefore  assumed, 
as  follows  from  the  plate  of  Pirogoff  and  Jarjarvay,  that  this  urethral 
curvature  which  offers  in  the  normal  condition  frequent  variations  can 
only  be  generally  denned.  Moreover,  the  ease  with  which  instruments  can 
be  introduced  into  the  bladder  merely  by  their  own  weight  proves  that  it  is 
less  a  question  of  giving  the  catheter  a  definite  curvature,  than  of  knowing 
of  the  hindrances  which  might  oppose  its  introduction.  The  projection  in 
the  prostatic  portion  of  the  urethra  corresponds  to  the  prostatic  sinus  near 
the  colliculus  seminalis,  which  lies  in  the  section  with  the  ejaculatory  duct. 

The  relations  and  structure  of  the  glans  and  corpus  cavernosum  are 
well  shown,  so  also  is  the  fossa  navicularis.  The  other  dilatations  and 
contractions  of  the  urethra  which  are  regular  in  the  normal  body  cannot 
be  defined.  In  order  to  obtain  a  clear  idea  of  these,  casts  must  be  made 
from  soft  specimens  as  Langer  has  done,  as  sections  of  hard  prepara- 
tions are  not  of  much  value.  The  position  of  Cowper's  glands,  which  lie 
so  deeply  below  the  urethral  muscles,  will  explain  why  the  inflammation 
and  enlargement,  which  are  frequently  found  on  section  to  have  affected  them, 
are  so  little  regarded  during  life ;  a  considerable  amount  of  swelling  must 
occur  in  order  to  afford  any  perceptible  tumour. 

If  the  plate  be  examined  with  regard  to  perineal  operations,  such 
as  lithotomy,  one  is  astonished  at  the  narrowness  of  the  space  between 
the  upper  portion  of  the  urethra  and  the  rectum.  It  must  be  remarked, 
however,  that  in  the  present  instance  it  is  peculiarly  exaggerated,  as  the 
rectum  was  full  of  faeces. 

The  importance  of  the  rule  is  evident  that  before  the  operation  of 
lithotomy  be  undertaken  the  rectum  be  cleared  of  all  faecal  matter,  in 
order  that  it  be  out  of  the  reach  of  the  knife.  That  the  space  is  thereby 
substantially  enlarged  is  manifest  from  Kohlrausch's  plate,  which  is  drawn 
from  a  greatly  distended  rectum. 

It  is  further  seen  from  the  relations  before  us,  that  it  is  quite 
practicable  to  preserve  the  capsule  of  the  prostate.  By  dilating  the  mem- 


1G  PLATE   I 

branous  and  prostatic  portions  of  the  urethra  more  room  is  obtained  for 
entering  the  bladder,  as  well  as  for  the  removal  of  large  calculi.  By  the 
preservation  of  the  posterior  part  of  the  prostate  with  its  capsule,  dangerous 
urinary  infiltration  is  obviated.  With  regard  to  the  high  operation  of 
lithotomy  above  the  symphysis  there  is  nothing  to  remark.  The  plate  also 
shows  that  the  bladder  must  be  fully  distended  in  order  that  that  part  of  it 
which  is  not  covered  by  peritoneum  may  be  raised  sufficiently  above  the 
level  of  the  pubic  symphysis. 


Tab.!  A. 


PLATE   II  (A,B) 

THIS  section  was  made  on  the  body  of  a  finely  formed  woman  (twenty- 
five  years  of  age),  which  was  brought  into  the  dissecting  room  immediately 
after  death  by  hanging.  The  arteries  were  injected  with  paint,  the  body 
laid  on  the  back  and  frozen,  and  the  details  of  the  section  carried  out  as  in 
the  last  case. 

The  uterus  was  found  to  contain  a  foetus  of,  probably,  the  eighth  week. 
All  the  organs  were  normal.  The  stomach  and  intestines  were  tolerably 
empty ;  the  transverse  colon  was  moderately  distended  with  flatus,  and  the 
rectum  with  fasces.  The  bladder  was  contracted,  and  as  no  urine  had  flowed 
from  it  during  the  transport  of  the  body,  it  was  probably  empty  at  the  time 
of  death. 

The  section  was  carried  from  below  upwards,  chiefly  in  order  to  divide 
the  pelvis  in  the  middle  line,  and  was,  on  the  whole,  very  successfully 
directed.  The  articulation  of  the  symphysis  was  opened,  and  so  also 
were  the  urethra  and  lowest  part  of  the  rectum. 

On  the  other  hand,  the  uterus,  which  lay  somewhat  on  the  left  side,  was 
cut  through  in  its  right  half,  yet  so  near  the  middle  line  that  it  was 
necessary  to  remove  a  thin  slice  only  in  order  to  show  the  canal  of  the 
cervix  throughout  its  extent.  The  spinal  canal  was  opened  throughout, 
and  very  near  to  its  middle  line. 

It  will  be  noticed,  from  the  appearance  of  the  dorsal  portion  of  the  cord, 
that  at  the  lower  part  of  the  thorax  the  vertebrae  are  cut  to  the  right  of  the 
middle  line,  and  from  the  appearance  of  the  great  vessels  of  the  abdomen, 
that  the  section  passes  through  the  diaphragm  between  the  caval  and  the 
aortic  apertures.  The  inferior  cava  is  entirely  removed  with  the  right  half 
of  the  body,  and  a  transverse  section  only  of  the  left  common  iliac  vein  is 

3 


18  PLATE   II 

seen ;  the  abdominal  aorta,  on  the  other  hand,  is  completely  shown,  with 
the  right  common  iliac  artery  divided. 

In  the  thorax  the  saw  has  passed  exactly  in  the  middle  plane ;  neither 
lung  is  seen  and  neither  pleural  sac.  As  regards  the  tongue,  a  small  lamina 
only  had  to  be  removed  to  expose  its  mesial  plane.  The  cerebrum  was  not 
cut  exactly  in  the  middle  line,  so  that  about  one  tenth  of  an  inch  of  the 
dura  mater  had  to  be  removed  in  order  to  expose  the  longitudinal  sinus  and 
to  accurately  halve  the  brain,  which  had  been  in  the  meanwhile  hardened 
with  spirit. 

Before  I  enter  upon  the  chief  points  of  importance  in  this  plate  or 
describe  the  pelvic  viscera,  I  shall  point  out  the  general  relations  of  the 
parts,  commencing  with  the  vertebrae. 

The  spinal  column  shows  a  very  beautiful  curve,  which  contrasts 
favorably  with  that  in  Plate  I.  On  account  of  the  slight  bending  back- 
wards of  the  head  the  cervical  vertebrae  do  not  project  so  far  forwards, 
and  the  dorsal  spine  does  not  curve  backwards  so  considerably,  but  passes 
more  gradually  into  the  convexity  of  the  lumbar  curve. 

If  a  line  be  drawn  parallel  with  the  long  axis  of  the  body,  commencing 
in  the  region  of  the  occipito-atloid  articulation,  and  then  passing  through  the 
posterior  border  of  the  odontoid  process  of  the  second  cervical  vertebra,  it 
would  touch  the  last  cervical  and  first  dorsal  vertebra  (in  Plate  I  it  touches 
the  three  lower  cervical),  and  pass  down  close  behind  the  promontory. 
The  line  passing  nearly  through  these  points  is,  according  to  Weber,  the 
line  of  gravity. 

The  inclination  of  the  pelvis  is  58°  (less  than  that  of  the  male  in  Plate  I, 
which  is  60°). 

The  slight  projection  of  the  promontory  is  characteristic  of  the 
female  spine,  as  opposed  to  that  of  the  male,  and  so  also  is  the  more 
abrupt  direction  of  the  symphysis  pubis.  It  is  evident  from  this  circum- 
stance that  the  conditions  are  more  favorable  for  the  expulsion  of  the  child, 
which  thus  glides  the  more  easily  downwards  on  to  the  promontory 
from  the  more  abrupt  surface  of  the  symphysis.  It  is  repeatedly  con- 
tested that  the  axis  of  the  symphysis  (by  which  is  understood  the  direction 
of  the  greatest  length  of  the  joint)  is  more  abrupt  in  the  female  than  in  the 


PLATE   II  19 

male,  and  from  this  an  impediment  to  parturition  has  been  sought.  I 
am  not  able  to  declare  whether  in  this  particular  a  constant  difference 
exists  between  the  male  and  female  pelvis.  From  a  series  of  sections 
on  frozen  bodies  I  have,  however,  found  this  relation  over  and  over  again, 
as  this  and  the  first  plate  show,  and  I  might  therefore  direct  the  attention 
of  gynaecologists  to  this  point,  for  I  am  unable  as  yet  to  give  any  decided 
opinion  upon  it. 

The  conjugate  diameter  is  very  large,* 4' 8  inches.  The  pelvis,  on  the 
whole,  is  wide,  but  is  not  otherwise  abnormal.  There  is  not  much  to  remark 
as  regards  the  head;  the  individual  parts  are  the  same  as  in  Plate  I.  It  is 
fortunate  that  the  mouth  was  firmly  closed,  as  the  two  incisor  teeth  shut 
upon  one  another  like  the  blades  of  a  pair  of  scissors.  The  tongue  com- 
pletely filled  up  the  mouth.  In  a  transverse  section  of  the  tongue  a 
shallow  furrow  is  generally  noticed  at  its  back,  which  passes  from  before 
backwards,  a  narrow  space  being  left  between  the  tongue  and  hard  palate ; 
hence  it  must  be  assumed  that  the  middle  line  of  the  tongue  was  not  in  this 
case  exactly  in  the  line  of  section.  The  oesophagus,  in  which  was  some 
undigested  food,  admits  of  delineation  throughout  its  entire  extent,  but  on 
account  of  the  shading,  it  is  not  satisfactorily  represented  in  its  original 
position;  against  the  third  dorsal  vertebra  the  shading  is  not  intense 
enough  to  show  its  deep  excavation.  At  the  level  of  the  sixth  and  seventh 
dorsal  vertebrae,  on  account  of  the  small  piece  cut  off,  more  of  the 
oesophagus  lies  on  the  right  half  of  the  body,  and  consequently  its  course 
forms  a  flat  $-curve  in  the  frontal  plane. 

In  front  of  the  trachea  lies  in  section  a  considerably  developed  thyroid 
body,  which  causes  a  slight  bulging  forwards  of  the  neck.  Beneath  this 
lies  the  left  innominate  vein,  and  close  to  it  are  the  remains  of  the 
thymus  gland ;  behind  the  vein  is  the  ascending  aorta  with  a  section  of  the 
innominate  artery.  The  course  of  the  innominate  artery  with  regard  to 
the  trachea  is  of  considerable  surgical  importance.  An  incision  made  in 
the  mesial  line  of  the  neck  between  the  thyroid  body  and  the  upper  border 
of  the  sternum  would  reach  the  vessel  as  it  lies  on  the  trachea.  Ligature 
of  this  vessel  has  hitherto  not  been  successful,  owing  to  shortness  of  the 
trunk  (from  one  inch  to  an  inch  and  three  fifths).  It  is  not  to  be  wondered 


20  PLATE   II 

at  that  the  conditions  for  the  formation  of  a  firm  coagulum  are  here 
unfavorable.  It  must  also  be  borne  in  mind  that  the  incision  made  to 
search  for  the  vessel  is,  like  that  made  in  tracheotomy,  below  the 
thyroid  body,  and  that  at  the  lower  end  of  the  wound  the  left  innomi- 
nate vein  may  be  met  with.  The  trachea,  which  when  extended  lies  on 
the  anterior  surface  of  the  oesophagus,  divides  into  its  two  bronchi  in 
front  of  the  fourth  dorsal  vertebra,  as  is  shown  in  the  section  represented 

in  Plate  I. 

I  was  much  surprised  by  the  apparent  shortness  presented  by  the 
trachea  in  the  section  of  a  frozen  body  made  with  the  head  depressed, 
and  by  its  becoming  very  considerably  extended,  when  at  the  com- 
mencement of  thawing  I  reinstated  the  head  in  its  normal  position.  It 
is  owing  to  this  extensibility  of  the  trachea — due  solely  to  the  elastic 
tissue  between  the  cartilaginous  rings — that  positions  of  extensive  flexion 
and  extension  of  the  head  can  be  taken  up  without  thereby  causing 
dislocation  of  the  roots  of  the  lungs.  Were  the  trachea  a  uniformly  solid 
tube  it  must  follow  that  at  each  flexion  of  the  head  it  would  be  pushed 
dangerously  upon  the  root  of  the  lung  and  left  auricle,  whilst  on  each 
abrupt  jerking  back  of  the  head  the  thoracic  viscera  would  be  dislocated 
upwards  by  the  sudden  drag.  Measurements  which  I  have  made  show 
that  the  amount  of  extensibility  of  the  trachea  during  flexion  and  extension 
of  the  head  is  about  one  inch,  and  that  there  is  no  considerable  folding  or 
pinching-up  of  tissue  in  its  inner  wall.  This  peculiar  condition  also 
accounts  for  the  wide  gaping  of  all  transverse  wounds  of  the  trachea  during 
extension  of  the  head. 

Of  still  further  practical  importance,  particularly  with  relation  to  the 
performance  of  tracheotomy,  is  the  variation  in  the  relative  position  of  the 
trachea  and  the  anterior  surface  of  the  neck  in  the  different  positions  of  the 
head.  During  extreme  extension  of  the  head  the  trachea  is  brought  con- 
siderably nearer,  the  surface  of  the  neck,  and  is  consequently  more  acces- 
sible ;  moreover,  the  field  for  operation  is  much  more  extensive  than  when 
the  chin  is  in  the  usual  position  of  depression.  The  section  given  by  Pirogoff 
(1.  A,  14,  1 )  is  remarkably  instructive  on  this  point.  Again,  with  the  exten- 
sion and  advancement  of  the  trachea,  the  arch  of  the  aorta  and  the 


PLATE   II  21 

innominate  artery  are  drawn  somewhat  higher,  and  in  this  way  the  latter 
vessel  is  rendered  more  accessible  for  ligature. 

As  regards  the  heart,  its  left  auricle  was  distended,  owing  to  the 
injection  having  entered  it  from  the  lungs,  thus  the  appearance  presented 
by  these  parts  is  normal.  The  oval-shaped  section  of  the  distended 
left  auricle  is  seen  close  to  the  oesophagus,  before  the  more  triangular 
opening  in  the  right  auricle.  A  small  portion  of  the  right  ventricle  is 
opened  by  the  section.  From  both  auricles  the  corresponding  ventricles 
can  be  seen  through  the  auriculo- ventricular  openings ;  these  parts,  after 
careful  cleansing,  are  shown  in  their  hardened  condition.  In  the  left 
auricle  is  seen  the  entrance  of  the  pulmonary  veins,  in  the  right  the 
coronary  sinus.  The  sinus,  with  the  valves  of  Thebesius,  are  shown  in  the 
lowest  part  of  the  triangular  section  of  the  right  auricle.  A  portion  of  the 
valvular  apparatus  can  be  seen  in  the  divided  arch  of  the  aorta ;  behind 
the  vessel  lies  the  right  branch  of  the  pulmonary  artery.  A  small  portion 
of  the  right  auricular  appendage  which  was  left  in  the  left 'half  of  the  body 
(also  agreeing  with  the  section  in  Plate  I),  was  removed,  so  that  a  con- 
siderable space  is  left  in  front  of  the  aorta  inside  the  pericardium. 

If  the  section  of  the  thoracic  cavity  be  compared  with  that  of  the  young 
man  (Plate  I)  it  will  at  once  be  observed  that  the  upper  border  of  the 
manubrium  of  the  sternum  is  half  the  depth  of  a  vertebra  higher  in  the 
male,  and  about  yth  of  an  inch  further  from  the  spine  than  in  the  female. 
In  the  female  the  upper  border  of  the  sternum  corresponds  with  the  space 
between  the  second  and  third  dorsal  vertebrae.  The  greater  capacity  of 
the  male  thorax  is  also  demonstrated  from  the  fact  of  the  diaphragm 
reaching  to  the  level  of  the  nbro-cartilage  between  the  ninth  and  tenth 
dorsal  vertebrae,  whereas  in  the  female  its  highest  point  corresponds  with 
the  upper  border  of  the  ninth,  and  is  consequently  the  depth  of  an  entire 
vertebra  higher.  We  have  to  deal  here  with  a  well-proportioned  though 
greatly  developed  female,  but  as  the  two  subjects  were  of  the  same  age  it 
will  be  of  great  advantage  to  compare  them.  It  appears  that  the  position 
of  the  several  parts  of  the  heart  in  both  is  nearly  similar  as  regards  the 
mesial  line.  (In  both  cases  the  auricles  and  a  small  portion  of  the  right 
ventricle  appear  in  the  section.) 


22  PLATE   II 

Nothing  is  seen  of  the  lungs  in  young  persons  in  such  a  preparation  in 
consequence  of  the  presence  of  the  thymus  gland;  in  the  condition  of 
expiration  their  anterior  edges  never  reach  the  middle  line,  consequently 
a  median  vertical  section  does  not  expose  lung  tissue.  In  old  persons, 
in  consequence  of  the  dwindling  away  of  this  organ  and  of  the  slight 
capability  of  contraction  of  the  lungs,  they  meet  one  another  after  death 
anteriorly ;  and,  moreover,  the  right  lung  frequently  overlaps  the  left  half 

of  the  body. 

On  account  of  the  slight  distension  of  the  intestines  the  cavity  of  the 
abdomen  showed  but  little  prominence,  but  not,  however,  an  actual  in- drawing 
of  the  abdominal  walls  as  one  observes  in  sections  of  bodies  which  have 
become  emaciated  from  sickness.  In  this  case,  from  the  amount  of  fat 
beneath  the  skin  and  in  the  abdomen  it  is  plain  that  the  individual  was  well 
nourished.  Also  in  this  particular  the  circumstances  closely  resemble  those 
of  Plate  I,  although  there  is  a  considerable  difference  with  regard  to  the  depth 
of  the  abdominal  cavity.  In  consequence  of  the  greater  distension  of  the 
stomach  and  intestines  in  the  male  subject,  which  is  manifest  from  the 
greater  extent  of  the  section  through  the  intestines,  and  that  in  the  female 
the  arteries  were  injected  and  the  gravid  uterus  pushed  a  portion  of  the  small 
intestine  upwards,  the  distance  of  the  abdominal  wall  from  the  vertebra 
at  the  level  of  the  twelfth  dorsal  vertebra,  in  this  plate,  amounts  to, 
nevertheless,  2  inches  less,  whilst  in  the  region  of  the  umbilicus  the  depth 
of  the  abdominal  cavity  is  much  the  same  in  each,  viz.  about  3'5  inches.  It 
is,  moreover,  to  be  borne  in  mind  that  in  the  male  spine  the  concavity  of 
the  dorsal  region  begins  lower  down,  is  more  decided  than  in  the  female, 
and  further,  that  the  bladder  in  this  instance  is  empty  and  in  the  other 
tolerably  full. 

The  section  has  so  fallen  through  the  abdomen  that  the  diaphragm  has 
been  met  with  between  the  oesophageal  and  caval  openings  more  towards  the 
right  side  of  the  spine,  so  that  the  abdominal  aorta  is  not  divided  as  in 
Plate  I,  but  remains  intact  on  the  upper  surface.  In  order  to  make  the 
artery  more  clear  for  the  drawing,  only  a  small  layer  of  cellular  tissue  was 
removed  so  as  to  render  distinct  its  plastic  appearance.  At  its  inferior 
extremity  is  the  divided  right  common  iliac  artery ;  nothing  is  to  be  seen 


PLATE   II  23 

of  the  inferior  cava  (which  remains  in  the  right  half  of  the  body)  but  a 
small  portion  close  to  the  left  common  iliac  vein.  In  like  manner  (as  in 
Plate  I)  the  trunk  of  the  superior  mesenteric  vein  is  divided  at  the  point 
where  it,  after  receiving  the  splenic  vein,  courses  over  to  the  right  side, 
opposite  the  pancreas,  and  passes  to  the  liver  as  the  portal  vein.  In  front 
of  the  lower  end  of  this  vein  is  the  superior  mesenteric  artery. 

The  pancreas,  though  not  so  broad  as  in  Plate  I,  has  a  similar  position 
at  the  level  of  the  first  lumbar  vertebra.  The  superior  mesenteric  vein 
passes  through  the  (lesser)  pancreas  throughout  its  extent.  The  duodenum, 
which  was  tolerably  empty  and  flattened  by  the  injected  vessels,  appears 
as  a  narrow  cleft  in  front  of  the  second  or  third  lumbar  vertebrae, 
at  the  inferior  end  of  the  lesser  pancreas.  In  Plate.  I,  in  consequence 
perhaps  of  the  greater  development  of  the  lesser  pancreas,  it  lies  some- 
what deeper. 

A  small  piece  of  the  lobulus  Spigelii  of  the  liver,  which  is  covered  by 
peritoneum,  is  seen  remaining  in  the  left  half  of  the  body.  The  compli- 
cated arrangement  of  the  peritoneum  in  this  region  can  be  understood 
by  consulting  Plate  XV,  which  represents  a  transverse  section  at  the  level 
of  the  eleventh  dorsal  vertebra,  and  thus  accidentally  corresponds  to  the 
section  which  separates  both  plates. 

The  stomach  was  empty  and  contracted,  but  the  transverse  colon, 
which  was  considerably  distended  with  gas,  hung  down  like  a  sling,  and  was 
therefore  divided  to  a  greater  length.  There  is  no  peculiarity  to  be  noticed 
in  the  small  intestine.  A  portion  of  the  ileum  is  pushed  up  out  of  the  pelvis 
by  the  uterus,  and  therefore  the  lumina  of  the  intestines  fill  up  the  abdominal 
cavity  higher  than  in  Plate  I.  We  must  here  consider  the  relations  of  the 
rectum  more  attentively.  It  was  evenly  distended  with  frozen  faecal 
matter,  and  was  of  great  calibre.  The  anus  is  directed  backwards  as 
in  the  upright  position,  a  direction  dependent  on  the  inclination  of  the 
pelvis ;  but  in  the  sitting  position,  when  the  equilibrium  of  the  trunk  is 
maintained  by  the  tuberosities  of  the  ischium,  the  symphysis  is  raised  .so 
considerably  that  the  conjugate  diameter  is  nearly  horizontal,  and  the 
anus  takes  a  direction  directly  downwards.  Above  its  lowest  curve,  at  the 
level  of  the  coccyx,  is  a  transverse  fold,  which  is  the  commencement  of 


24  PLATE   II 

the  valves  of  the  rectum  of  Kohlrausch.  Higher  up  the  rectum  gradually 
passes  over  towards  the  left  side,  and  afterwards  it  crosses  the  middle 
line  again  by  a  sharper  curve  to  fall  a  second  time  into  the  plane  of  section. 
From  the  transversely  divided  lumen  of  bowel,  which  lies  in  front  of  the 
third  and  fourth  pieces  of  the  sacrum,  the  rectum  appears  again  more 
in  the  middle  line,  and  following  the  curvature  of  that  bone,  terminates 
in  the  iliac  flexure.  The  rectum  thus  forms  a  double  S  curve ;  one  portion 
lying  in  the  antero-posterior  plane  of  the  body,  the  other  in  the  trans- 
verse. These  bendings  serve  to  support  the  sphincter-apparatus  during 
the  pressure  of  the  faecal  matter,  so  that  at  the  time  of  defecation  a 
resistance  is  afforded  which  would  not  exist  were  the  direction  of  the 
rectum  vertical.  It  will  be  observed  also  that  the  name  rectum,  which  has 
been  applied  to  this  portion  of  the  intestine,  is  incorrect ;  it  originated 
from  the  old  representations  which  were  made  from  undistended  intestine 

and  soft  preparations. 

In  front  of  the  rectum,  between  it  and  the  contracted  bladder,  is  the 
gravid  uterus.  Considerable  interest  is  claimed  for  this  section,  from  the 
fact  of  the  womb  being  in  a  state  of  gestation  corresponding  with  the 
end  of  the  second  month. 

I  am  unable  to  say  how  it  happens  that  the  body  of  the  uterus  is   so 

sharply   bent   against  its  neck  and  turned  backwards,  for  its  tissues  are 

absolutely  normal,  and  according  to  the  statement  of  Hoist  ('  Beitrage  zur 

Geburtskunde,'  1  H.,  Tubingen,  1868,  p.  162)  at  this  period  of  pregnancy 

anteflexion  rather  than  retroflexion  would  be  expected.     I  can  only  with 

difficulty  accept  the  proposition  that  the  uterus  during  life  had  some  other 

position   originally,  and    that    directly   after   death,  when   the   body  was 

placed  on  its  back,  it  sank  down  from  its  own  weight.     At  the  same  time  it 

must  be  admitted  that  the   space  between  the   uterus  and   rectum   was 

previously  occupied  by  small  intestine,  and  yet  we  cannot  imagine  that 

they  slid  upwards  in  order  to  make  room  for  the  body  of  the  uterus.     The 

subject  presented  throughout  firm  tissues  and  strong  muscles,  and  there 

were  no  signs  of  a  previous  pregnancy.     The  relations  of  the  intestines 

are  normal;   no  coils  lie  between  the  uterus  and  rectum,  or  uterus  and 

bladder. 


PLATE   II  25 

The  deep  situation  of  the  external  orifice  of  the  uterus,  from  which  a 
firm  plug  of  mucus  projects,  corresponds  with  early  pregnancy.  Later  on 
the  uterus  rises  up  out  of  the  pelvis  and  draws  the  vaginal  portion  up  with 
it,  so  that  the  external  os  takes  a  higher  position. 

The  uterus  itself  inclined  somewhat  towards  the  left  side,  so  that  the 
plane  of  section  passed  obliquely  through  its  long  axis,  and  only  a  small 
portion  of  it  was  removed  with  the  right  half  of  the  body. 

The  hinder  lip  of  the  cervix  appeared  as  if  it  had  slipped  away,  and 
wanted  only  a  thin  slice  more  to  be  cut  off  in  order  to  expose  the  canal  of 
the  cervix  throughout  its  length. 

The  bag  of  the  amnion  was  untouched,  and  the  umbilical  vesicle 
was  clearly  evident.  I  have  removed  from  the  wall  of  the  uterus  suc- 
cessive layers  so  that  the  individual  parts  of  the  ovum  may  be  seen 
distinctly. 

On  the  inner  side  of  the  muscular  tissue  of  the  uterus  can  be  seen  the 
decidua  vera,  consisting  of  uterine  follicles,  cellular  tissue,  and  blood- 
vessels. The  round  openings  of  the  follicles  could  be  easily  seen  with  the 
naked  eye  on  the  inner  and  upper  surfaces.  Above,  commencing  in  the 
anterior  wall  of  the  uterus,  the  decidual  layer  is  extremely  thin,  but  it 
gradually  increases  on  the  posterior  surface,  and  in  the  neighbourhood  of 
the  internal  uterine  orifice  it  is  still  thicker.  Corresponding  to  the  thinnest 
spots,  at  about  the  middle  of  the  fundus,  the  decidua  reflexa  is  shown  as 
a  fold  over  the  triangular  clot  of  blood.  It  is  one  of  the  thin  envelopes  of 
the  ovum,  and  is  most  external.  It  is  formed  from  the  chorion  Isevis  and 
the  decidua  reflexa,  and  upon  it  are  found  remains  of  epithelium,  connective 
tissue,  and  rudimentary  tufts. 

From  the  position  of  the  effused  blood  (which  is  accurately  repre- 
sented) a  slender,  whitish  line  runs  backwards  and  upwards,  dividing  the 
chorion  frondosum  from  the  decidua  vera.  The  portion  of  the  chorion 
which  is  shown  in  the  plate  contains  only  tufts  and  vessels ;  it  indicates  the 
place  of  formation  of  the  placenta.  In  this  neighbourhood  the  umbilical 
cord  is  already  discernible  as  it  runs  deeply  downwards. 

Inside  the  chorion  was  a  viscid  fluid,  in  which  floated  the  sac  of  the 
amnion,  the  vitelline  duct,  and  umbilical  vesicle.  Distinct  membranes 

4 


26 


PLATE   II 


between  the  chorion  and  amnion  were  not  made  out  in  the  fluid.  The 
embryo  shows  the  usual  curvature  of  the  trunk  with  the  head  bent 
forwards.  Its  length,  from  the  coccyx  to  the  head  as  it  lay  in  its  original 
position  was  about  four  fifths  of  an  inch,  and  when  stretched  out  it  was 
about  one  inch  and  a  fifth. 

The  cranium  was  so  enveloped  by  its  coverings  that  the  division  of  the 
brain  could  not  be  seen  clearly  through  them.  The  nose  was  small,  but 
already  formed.  The  lateral  parts  of  the  oral  cavity  (the  cheeks  and  lips) 
were  already  so  developed  that  the  mouth  appeared  as  a  circumscribed 
fissure.  The  upper  and  fore  arms  were  flexed  and  separated ;  the  hands 
were  discernible  and  the  lower  extremities  were  in  a  proportionate  stage  of 
development.  These  conditions  correspond  with  the  development  of  an 
embryo  described  by  Erdl  ('  Die  Entwickelung  des  Menschen  und  Huhnchens 
im  Eie,'  Leipzig,  1845,  taf.  iii,  6,  iv,  18,  ix,  3  and  4). 

The  umbilical  vjesicle  is  represented  too  tense  and  large.  It  lay  on  the 
closed  amnion  as  a  flaccid  bag,  looking  like  a  membranous  disc,  of  the  size 
of  a  lentil,  or  about  one  fifth  of  an  inch  in  diameter. 

The  vagina,  divided  through  its  anterior  and  posterior  rugae,  appears  as . 
a  narrow  fissure,  and  is  continued  upwards  behind  the  posterior  lip  of  the 
external  os. 

The  right  sacral  ligament  of  the  uterus  is  seen  in  the  bundles  of  fibrous 
tissue  here  divided.     The  fibres  do  not  admit  of  being  clearly  discerned 
from  the  muscular  tissue  of  the  uterus,  but  show  themselves  merely  as  a 
transversely   divided   bundle,   the   continuation  of  which   in   the   fold  of 
Douglas  grasped  the  rectum  on  both  sides  and  extended  to  the  sacrum.     It 
cannot  be  accurately  defined  where  the  vagina  ends  and  the  uterus  begins. 
The  muscular  fibres  of  both  organs  lay  so  close  together,  and  were  so  inter- 
laced, that  they  are  represented  as  being  in  continuity.     It  is  clear  from  the 
plate  that  the  peritoneum  stretches  further  down  behind  the  uterus  than  in 
front,  and  that  it  covers  a  small  portion  of  the  wall  of  the  vagina.     A  thin 
process  of  fascia  is  united  to  this  by  lax  cellular  tissue,  which  permits  of  a 
shifting  of  the  rectum  and  vagina  in  their  mutual  distension.     I  have  found 
the  connexion  between  the  bladder  and  cervix  uteri  so  arranged  that  the 
possibility  of  considerable  distension  of  the  bladder,   and  of  the  anterior 


PLATE   II  27 

wall  of  the  vagina,  and  a  rising  of  the  uterus  would  be  permitted.  The 
ascent  of  the  base  of  the  bladder  is  not  possible  if  it  were,  as  is  stated 
by  Courty,  adherent  to  the  cervix  (Courty,  '  Maladies  de  1' uterus,'  Paris, 
1866,  page  11). 

The  clitoris  is  shown  with  its  right  crus  divided.  Behind  it,  and  in 
front  of  the  urethra,  lie  the  divided  blood-vessels  of  the  bulb  of  the  vestibule. 
The  urethra  opened  of  itself  after  the  thawing  of  the  preparation,  and  is 
shown  in  the  dilated  condition.  In  the  tissue  in  front  of  and  behind  the 
urethra  was  found  (by  means  of  the  microscope)  a  layer  of  striped  muscular 
fibre  which  forms  the  sphincter  of  the  urethra.  I  was  not  able  to  obtain  a 
well-made  female  subject  for  section,  nor  did  I  succeed  in  getting  a  body 
affected  with  well-marked  anomalies  in  as  regards  the  position  of  the  uterus. 
It  is,  however,  of  great  practical  interest  to  compare  the  plane  sections  of 
such  a  body  with  the  plate ;  I  therefore  give  a  series  of  reduced  copies  from 
Legendre  and  Pirogoff,  with  the  idea  of  making  this  work  as  complete  as 
possible.  The  bladder  in  fig.  1  contained,  according  to  Legendre,  nearly 
one  pint  of  urine.  The  peritoneum  at  its  reflexion  from  the  bladder  was 
two  inches  from  the  symphysis,  and  its  distance  behind  the  uterus  from  the 
perineum  was  2*08  inches.  The  conjugate  diameter  was  4*2  inches ;  that 
of  the  outlet  was  2*4  inches. 

Although  a  decidedly  atrophic  uterus  is  here  represented,  the  plate 
must  be  accepted,  as  I  sought  in  vain  for  a  better  specimen.  The  distended 
bladder  has  lifted  the  peritoneum  some  way  from  the  symphysis,  and 
has  pushed  the  uterus  downwards  and  backwards.  The  form  of  the 
bladder  is  not  that  usually  found  in  young  persons.  The  spindle  shape 
which  is  so  characteristic  in  children  persists  for  some  long  time,  whereas 
the  rounder  form  is  met  with  in  old  persons.  It  is  not  improbable  that 
Legendre  had  removed  the  viscera  from  the  subject  the  preparation  was 
made  from,  which  would  account  for  no  sections  of  intestines  being  seen 
excepting  the  rectum,  as  well  as  for  abdominal  walls  being  cut  off  shorter 
than  the  spinal  column.  Should  this  have  bsen  the  case,  the  form 
he  has  given  to  the  bladder  is  explained ;  a  bladder  lying  freely  is 
distended  in  a  different  manner  from  one  which  lies  in  the  closed  ab- 
dominal cavity,  as  can  be  easily  proved  by  experiment.  On  the  other  hand, 


28 


PLATE   II 


the  level  of  the  reflexion  of  the  peritoneum  above  the  symphysis  agrees  with 
that  given  in  the  young  subject  which  Legendre  figures.  In  young  persons 
only  can  we  reckon  that  in  distension  of  the  bladder  so  much  space  would 
be  gained  that  in  extracting  a  calculus  above  the  symphysis  a  sufficiently 
large  vertical  incision  can  be  made  without  wounding  the  peritoneum  ;  in 

Fio.  1. 


Pelvis  of  virgin,  set.  18.     Legendre,  '  Anat.  Homalographique  Paris,'  1868,  pi.  xvii. 
1.  Uterus.        2.  Bladder.        3.  Rectum.        4.  Symphysis. 

old  persons  the  space  is  very  limited  in  a  transverse  direction.      Between 
the  uterus  and  the  rectum  no  coils  of  intestine  are  seen. 

The  following  plate  from  Pirogoff  merely  shows  the  bladder  and  urethra 
fully  distended  in  order  to  demonstrate  the  anatomical  relations  of  the  high 
operation  and  the  vestibular  incision  for  stone. 


PLATE   II 


29 


A  thorough  distension  of  the  bladder  left  the  peritoneum  an  inch  and  a 
half  from  the  symphysis,  and  by  the  traction  on  the  anterior  wall  of  the 


FIG.  2. 


Female  pelvis  ;  bladder  and  urethra  distended.     Pirogoff,  viii,  A,  32,  fig.  20. 
1.  Uterus.        2.  Bladder.        3.  Rectum.        4.  Symphysis. 


vagina  the  uterus  is  drawn  upwards  and  backwards.     The  conjugate  axis  is 
4*08  inches.     The  rectum  is  empty  and  contracted. 

The  extent  to  which  the  position  of  the  uterus  varies  with  distension  and 
evacuation  of  the  bladder  is  well  shown  in  figs.   2  and  3.     The  section  in 


30 


PLATE   II 


fig.  3  has  not  gone  exactly  through  the  mesial  plane,  and  thus,  although 
the  uterus  is  bisected,  the  anus  and  the  urethra  have  escaped  division.  In 
fig.  2  we  have  exactly  the  opposite  conditions,  namely,  an  empty  bladder 


FIG.  3. 


Female  pelvis,  set.  35  ;  normal ;  bladder  empty,  rectum  distended.     Pirogoff,  iii,  A,  21,  fig.  3. 
1.  Uterus.        2.  Bladder.        3.  Rectum.        4.  Symphysis. 


and  distended  rectum ;  consequently  the  relations  of  the  uterus  and  vagina 
are  altered.  Whereas  in  fig.  2  the  uterus  follows  the  axis  of  the  vagina,  in 
this  instance  it  forms  an  obtuse  angle  with  it,  without,  however,  being 


PLATE   II 


31 


anteverted.     No  coils  of  intestine  lie  between  the  uterus  and  rectum.     The 
conjugate  diameter  is  4*41  inches. 

The  uterus  in  fig.  4  with  all  its  connections,  was  normal,  and  lay  between 


FIG.  4. 


Pelvis  of  a  female  of  middle  age;  multipara ;  normal.     Pirogoff,  iii,  A,  22,  fig.  1. 
1.  Uterus.        2.  Bladder.        3.  Rectum.        4.  Symphysis. 


the  moderately  distended  bladder  and  rectum ;  nor  do  coils  of  intestine  lie 
behind  the  uterus  in  this  section.  It  will  be  noticed,  therefore,  that  in  the 
different  degrees  of  distension  of  the  bladder  and  rectum  the  uterus  is 


32 


PLATE   II 


always  in  the  middle  line  between  these  viscera,  whilst  its  position  varies 

with  its  volume. 

The  uterus  in  this  figure  lies  considerably  deeper  than  in  the  foregoing 
ones.     The  conjugate  diameter  is  4'2  inches. 


FIG.  5. 


Female  pelvis,  set.  30;  multipara;  anteflexion  of  uterus.     Legendre,  xviii. 
1.  Uterus.        2.  Bladder.        3.  Rectum.        4.  Symphysis. 

Fig.  5  (from  Legendre),  from  a  section  of  a  frozen  body,  made  after 
the  removal  of  the  viscera,  shows  well-marked  anteflexion  of  the  uterus. 

The  angle  between  the  body  and  neck  of  the  uterus  impinges  upon  the 
rectum.  The  walls  of  the  uterus  appear  throughout  of  uniform  thickness, 
and  the  rectum  and  bladder  are  but  slightly  encroached  upon. 


PLATE   II  33 

The  bladder  may  be  so  compressed  in  the  middle  line  that  it  assumes 
an  hour-glass  form,  one  portion  of  it  still  retaining  the  urine  after  the 
other  has  been  emptied  by  the  catheter.  In  such  conditions  the  catheter 
would  have  to  be  passed  into  the  further  cavity,  so  that  all  the  urine  might 
be  drawn  off. 

The  anterior  lip  of  the  os  is  continued  into  the  anterior  wall  of  the 
vagina  without   a  clearly    defined   border,    whilst   the  hinder  is    strongly 
prominent  and  has  a  length  of  one  inch.     The  cavity  of  the  vagina  contains 
the  canal  of  the  cervix.     The  vagina  itself  is  3  inches  in  length,  whilst  that 
in  fig.  4  was  only  1-5  inch,  and  the  long  extended  one  in  fig.  2,  2'8  inches. 
In  like  manner  the  distance  of  the  peritoneum  on  the  posterior  wall  of  the 
vagina  from  the  perineum  is  increased,  being  3 '24  inches  ;  in  fig.   1  it  is 
2'08  inches.     The  conjugate  diameter  is  large,  being  4*28  inches.     The 
ante-flexed  position  of  the  uterus  is  shown  by  Schultze  to  be  the  normal 
one  in  young  persons  when  the  bladder  is  empty.     The  uterus  would,  fol- 
lowing the  contracting  bladder,  lie  upon  it,  and  from  traction  exercised  by 
the  utero-vesical  ligament  of  Courty  extend  the  base  of  the  bladder  back- 
wards (cf.  Volkmann,  '  Sammlung  Klinisches   Yortrage,'  No.  50).     There 
is  no  question  that  during  the  variations  of  the  forms  of  the  rectum  and 
bladder,  according  to  the  amount  of  their  contents,  a  space  remains  in  the 
pelvis  near  the  uterus,  which  must  either  be  temporarily  filled  with  small 
intestine,  or  render  necessary  a  larger  amount  of  variability  in  the  shape 
of  the  uterus  itself.     If  we  exclude  with  Claudius  and  Hennig  the  possi- 
bility of   a  filling-up   of   Douglas's   pouch  by  the  small  intestine,   in  the 
case  of  the  bladder  and  rectum  being  empty,  the  difficulty  of  representing 
the  topography  of  the  uterus  would  be  enormous,  as  is  evident  to  every 
experienced  anatomist.     We  have  the  choice  only,  either  with  Henke  to 
show  the  uterus  set  up  at  a  fixed  angle  with  the  vagina  surrounded  by 
small  intestine,  or  with  Schultze  to  represent  it  bent  over  on  the  bladder. 
However  important  it  may  be  to  determine  these  relations  accurately,  I  do 
not  think  that  it  can  be  done  at  present ;  in  any  case  I  should  not  follow 
Schultze's  statement  completely.     The  extension  of  the  base  of  the  bladder 
does  not  appear  to  me  in  Schultze's  plate  to  be  correct,  still  less  so  does 
the   assumption  of  a  forcing  of  the    same   by   means    of  a  ligament,  as 

5 


34 


PLATE   II 


Courty  describes.  The  lax  cellular  tissue  which  lies  between  the  uterus  and 
the  base  of  the  bladder,  and  in  which  a  large  number  of  thin-walled  veins 
run,  cannot  be  regarded  as  a  ligament  in  the  usual  sense  of  the  word,  and 


Fio.  6. 


Female,  set.  35,  after  childbirth ;  ante-flexion.     Legendre,  xix. 
1.  Uterus.        2.  Bladder.        3.  Rectum.        4.  Symphysis. 

is  not  shown  as  such  in  my  plates.     It  would  be  necessary  to  obtain  a 


— j      r  WWWM**    wo    A-icucooaA  v     \i\j    Vulcan,    a 

series  of  bodies  of  young  females  in  order  to  study  the  variations  of  the 
position  of  the  uterus  in  well-hardened  preparations. 


PLATE   II  35 

The  woman  (fig.  6)  died  immediately  after  childbirth ;  the  anteflexion 
also  was  recent,  brought  on  by  the  weight  of  the  heavy  body  of  the  uterus, 
which  had  a  capacity  of  about  two  fluid  ounces. 

The  flexion  is  so  considerable  that  the  body  and  neck  of  the  uterus  are 
almost  at  a  right  angle  with  each  other,  and  on  the  anterior  wall  a  distinct 
fold  is  formed.  The  posterior  wall  of  the  uterus  rests  on  the  rectum,  and 
presses  on  its  lumen,  &c.  The  vagina  is  distended  and  measures 
3*6  inches.  The  distance  of  the  peritoneum  on  the  posterior  wall  of  the 
uterus  from  the  perineum  is  3 "8  inches.  These  figures  consequently 
considerably  exceed  those  in  the  preceding  case. 

The  position  of  the  fundus  with  regard  to  the  firmly-compressed  bladder 
is  to  be  remarked  here,  so  also  the  position  of  that  portion  of  the  peritoneum 
which  lies  between  the  uterus  and  bladder  on  the  anterior  wall  of  the 
vagina.  In  the  normal  condition  of  the  uterus  its  end  lies  nearest  the  peri- 
toneum, whereas  it  is  here  in  the  middle.  It  is  further  to  be  noticed  that  the 
strong  attachment  of  the  posterior  portion  of  the  base  of  the  bladder  with 
the  neck  of  the  uterus  (which  as  already  mentioned  is  admitted  by  Courty) 
is  not  present  in  this  preparation,  otherwise  the  bladder  and  urethra  lying 
close  down  on  the  uterus  would  be  dragged  upwards.  Nevertheless,  the 
lax  cellular  tissue  and  fascia  between  these  viscera  is  not  so  capable  of 
distension  that  variations  in  the  position  of  the  uterus  could  continue 
without  any  influence  on  the  bladder.  We  notice  here  that  a  large  piece  of 
the  posterior  portion  of  the  base  of  the  bladder  has  been  drawn  upwards,  a 
condition  which  would  interfere  with  the  action  of  the  vesical  sphincter, 
and  consequently  cause  an  incontinence  of  urine.  The  conjugate  diameter 
is  very  large,  5  inches,  and  exceeds  that  in  PI.  II. 

The  ante-flexed  position  of  the  uterus  is  very  well  represented  by 
Legendre,  as  is  also  to  be  found  in  Pirogoff's  '  Atlas,'  and  in  Riidinger's 
'  Topogr.  Chirurgische  Anatomie,'  i,  II  Abtheilung,  taf.  ii. 

The  female  from  which  his  *  plate  was  made  died  shortly  after 
instrumental  labour,  and  was  soon  given  over  to  Riidinger,  who  froze  it 
and  obtained  a  good  section.  The  thick- walled  uterus  had  dragged  the  small 
intestine  upwards  and  lay  with  its  fundus  high  above  the  symphysis.  Here 
also  the  base  of  the  bladder  had  not  followed  the  traction  exerted  by  the 


36  PLATE   II 

ante-flexed  uterus,  so  that  the  statement  of  Courty  is  not  borne  out  in  this 


case. 


Fig.  7  shows  a  retro-flexion  of  the  uterus.  The  thick  hyperaemic  uterus, 
which  has  been  opened  at  one  spot  only  (1),  contains  masses  of  coagulated 
blood,  and  shows  retro-flexion  as  well  as  a  lateral  deviation.  The  body  of 

FIG.  7. 


Female  pelvis;  retro-flexion  of  uterus.     Pirogoff,  iii,  A,  31.  14. 
1.  Uterus.      2.  Bladder.       3.  Rectum.      4.  Symphysis. 

the  uterus  lay  more  in  the  left  half  of  the  pelvis,  and  the  neck,  which  was 
divided  throughout  its  length,  kept  its  original  position.  Such  a  condition 
of  the  uterus  would  cause  a  pressure  on  the  rectum  which  would  be 
increased  to  complete  compression  were  the  retro-flexion  more  extended. 

Therefore,  if  the  retro-flexion  be  very  considerable  a  stoppage  of  fseces 
may  be  expected,  but  ante-flexion,  as  the  preceding  figure  shows,  is  able  to 
produce  a  similar  result.  The  conjugate  diameter  was  4'4  inches. 


PLATE   II  37 

If,  with  a  view  of  forming  any  conclusions,  the  figures  here  given  be 
compared,  it  is  at  once  noticed  that  the  statement  of  Claudius  ("  Bericht 
liber  die  Naturforscherversammlung  zu  Giessen,"  1865,  '  Zeitschrift  fur 
Eationelle  Medizin,'  iii  Reihe,  23  B.,  p.  244),  according  to  which  the  normal 
uterus  is  not  so  movable  and  not  so  enclosed  on  all  sides  by  coils  of  small 
intestine  as  is  generally  represented,  is  quite  borne  out.  The  uterus  lies  so 
much  more  between  the  bladder  and  the  rectum,  that  Douglas's  pouch 
contains  no  small  intestine.  Corresponding  with  this  is  the  gravid  uterus 
in  PL  II,  A,  B,  in  closer  apposition  with  the  hinder  wall  of  the  pelvis. 
However,  as  I  have  mentioned  above,  I  am  not  able  to  express  myself 
precisely  on  this  matter. 

It  would  be  important  to  institute  further  investigations  on  preg- 
nant bodies  to  find  out  whether  the  sharp  bending  seen  in  PL  II, 
A,  B,  is  post  mortem  or  not;  at  all  events,  the  fact  of  lying  the  body 
on  its  back  cannot  alone  be  the  reason  of  it.  If  the  uterus  were 
ante-verted,  and  directly  after  death  sank  from  its  own  weight  into  the 
position  of  retro-flexion,  we  must  expect  that  during  life  there  may  have 
been  similar  variations  when  a  supine  position  is  taken  up  repeatedly  and 
for  a  long  time  at  once.  On  the  other  hand,  I  cannot  assent  to  the  state- 
ment of  Claudius,  when  he  affirms  that  the  bladder  by  its  filling  and  empty- 
ing communicates  no  movement  to  the  uterus.  I  have  already  mentioned 
that  one  can  demonstrate  that  an  influence  is  exerted  by  the  full  and  empty 
bladder  upon  the  site  of  the  uterus  on  the  dead  body,  also  on  the  living 
subject  the  variations  of  the  position  of  the  uterus  from  micturition  can  be 
made  out.  A  cup-like  sinking-in  of  the  upper  wall  is  shown,  moreover,  in 
the  empty  bladder  only,  when  the  subjects  are  not  very  fresh  and  the  urine 
has  been  voided  immediately  before  death.  The  round  and  empty  bladder 
with  its  firmly  contracted  thickened  walls  (Plate  II)  shows  the  normal 
relaxations  of  this  viscus  when  it  has  been  emptied  by  its  own  power  of 
contraction. 


PLATE  III 

PIROGOFF,  in  his  works  which  we  have  frequently  cited,  has  carried  out 
his  sections  of  the  human  body  in  three  directions,  and  upon  that  attempts 
to  establish  its  configuration.  It  might  be  expected,  as  a  matter  of  course, 
that  such  a  proceeding  could  be  applicable  in  geometrical  solids,  but  it  is 
not  sufficient  in  organised  bodies,  even  if  one  divided  such  a  body  into  as 
many  thin  laminae  as  possible.  In  organised  bodies  oblique  sections  in 
individual  places  show  far  more  than  purely  sagittal,  frontal,  and  transverse 
sections.* 

This  is  more  particularly  the  case  with  the  eye.  Supposing  it  be  desired 
to  give  not  merely  the  relation  of  the  globe,  but  to  include  the  structures 
in  its  immediate  neighbourhood,  we  must  aim  at  bringing  into  view  the 
connections  of  the  eye  with  the  optic  nerve  as  far  as  possible  up  to  the 
brain. 

It  is  of  only  secondary  interest  to  determine  in  which  horizontal  plane 
behind  the  orbit  the  individual  portions  of  the  temporal  lobe  lie.  In  order 
to  follow  the  course  of  the  optic  nerve  as  the  relations  on  the  skeleton 
indicate,  we  must  direct  the  plane  of  section  from  the  middle  of  the  pupil, 
obliquely  upwards. 

The  idea  of  this  proceeding  had  already  struck  Sommering,  and  in  his 
monograph  ('  De  Oculorum  Hominis  de  sectione  horizontali  commentatio,' 
Getting®,  1818)  a  very  useful  plate  is  given,  so  also  in  Pirogoff's  atlas  (fasc. 
i,  tab.  iii,  4,  5).  As  follows  from  Sommering's  work,  he  employs  the 

•  These  terms  are  in  frequent  use  in  this  work,  and  imply  respectively  a  vertical  section  by  a 
plane  passing  through  the  structures  in  an  antero-posterior  direction,  a  section  produced  by  a  plane 
also  passing  vertically,  but  at  right  angles  to  the  former,  whilst  a  transverse  section  implies  one 
made  at  right  angles  to  the  axis  of  the  trunk  or  extremities.— TB. 


Tab.  III. 


PLATE   III  39 

horizontal  only  as  opposed  to  the  longitudinal  section,  without  thereby 
meaning  that  he  adhered  to  a  horizontal  plane  which  was  accurately 
mathematical.  I  considered  it  profitable  to  conduct  the  section  in  the  same 
way  as  Sommering  has  done,  and  to  carry  it  up  tolerably  far  back.  I 
convinced  myself,  however,  from  a  large  series  of  sections,  that  we  are  not 
positively  able  to  determine  in  what  position  of  the  optic  nerve  or  tract  the 
saw  will  fall  from  the  front  inwards.  The  individual  differences  of  the 
base  of  the  skull  are  so  numerous  that  it  is  impossible  to  assign  to  them  any 
definite  data. 

Only  so  much  is  certain,  that  the  optic  tract  rises  up  from  the  chiasma 
to  the  corpora  quadrigemina  considerably  more  vertically  than  the  optic 
nerve  does  to  the  optic  foramen.  I  was  therefore  unable  to  expose  the  optic 
nerve  thoroughly  throughout  its  entire  length,  but  was  obliged  to  supple- 
ment the  section  by  taking  off  a  thin  slice  of  the  anterior  lobe  in  order  to 
completely  expose  the  chiasma.  Again,  a  thin  layer  of  fat  was  removed 
from  the  orbit  so  as  to  show  the  entire  breadth  of  the  nerve,  as  the  line  of 
section  had  just  missed  its  upper  edge. 

It  must  be  further  explained  that,  although  the  external  form  of  the 
globe  be  established,  the  relations  of  the  lens  and  iris  must  be  rendered 
after  further  sections.  The  fine  dust  which  even  such  a  thin  saw  produces 
was  very  difficult  to  remove  without  causing  a  change  in  the  relative 
position  of  the  individual  organs  of  the  eye.  I  therefore  froze  fresh  orbits, 
sawed  through  the  bones,  and  then  continued  the  section  with  a  razor.  In 
all  cases  the  eye  was  thoroughly  injected  with  Thiersch's  carmine  and  glue 
preparation,  in  order  to  give  the  globe  its  original  expansion.  The  injec- 
tion was  made  from  the  ophthalmic  artery,  and  in  the  entirely  divided  skull 
which  forms  PI.  Ill,  the  carotid  artery  and  jugular  vein  were  completely 
injected  with  different  colours. 

It  will  be  noticed  from  the  relations  of  the  brain  that  the  plane  of 
section  is  obliquely  upwards  and  backwards.  In  front,  owing  to  the 
removal  of  the  thin  lamina  of  the  anterior  lobe,  a  small  portion  of  the  floor 
of  the  skull  in  the  region  of  the  crista  galli  is  seen.  Behind  it  are  the 
optic  chiasma  with  a  small  piece  of  the  optic  tract  cut  obliquely,  and  further 
back  is  a  section  of  the  gyrus  fornicatus,  the  superior  processes  of  which 


40  PLATE   III 

lose  themselves  in  the  white  substance  of  the  cerebrum,  and  show  the  small 
bundles  of  fibres,  the  beak-shaped  processes  which  belong  to  the  fornix 
below. 

Externally  are  the  choroid  plexuses  of  the  descending  cornua.  Beneath 
the  white  substance  of  the  corpus  callosum  is  a  fissure  bounded  laterally 
by  the  optic  thalamus  and  filled  up  with  vessels,  and  in  the  middle  of  it  is 
the  pineal  body.  In  this  space  also  is  the  pia  mater  passing  beneath  the 
corpus  callosum  to  the  central  portion  of  the  cerebrum.  In  the  middle 
are  the  lumina  of  two  large  vessels  belonging  to  the  great  internal  veins  of 
the  brain,  the  vense  magnse  Galeni.  These,  when  followed  down  with  the 
sound  under  the  splenium  to  the  great  veins  behind  the  corpus  callosum, 
and  the  commencement  of  the  straight  sinus,  are  found  to  debouch  by  the 
two  veins  here  shown.  The  falx  cerebri  unites  the  inferior  longitudinal 
sinus  which  opens  into  the  straight  sinus,  with  the  superior  longitudinal 
which  lies  further  back. 

The  veins  of  Galen  curve  at  first  upwards,  and  then  bend  downwards 
into  the  straight  sinus.  It  would  be  worth  while  to  examine  whether 
during  the  movements  of  the  brain  in  respiration  any  influence  is  exerted 
on  the  venous  circulation  at  this  spot,  since  a  change  here  takes  place 
between  the  compressible  inner  veins  of  the  brain  and  the  rigid  walls  of 
the  sinus. 

In  front  are  the  optic  chiasma  and  the  optic  tract  cut  obliquely,  which 
consequently  are  more  vertical  than  the  plane  of  the  section. 

Internally  are  the  grey-edged  lentiform  nuclei,  and  behind  them  lie  the 
sections  of  the  optic  thalami.  Between  them  in  the  middle  line  is  a  portion 
of  the  third  ventricle. 

On  either  side  of  the  chiasma  are  the  internal  carotid  arteries  in  section. 
The  ophthalmic  arteries  are  not  seen,  as  they  enter  the  optic  foramina 
beneath  the  optic  nerves.  The  commencement  of  the  artery  of  the  corpus 
callosum  on  the  one  side  and  on  the  other  is  removed,  the  lumina  seen  being 
those  of  the  artery  of  the  fissure  of  Sylvius. 

The  orbits  were  so  divided  that  the  saw  passed  above  the  optic  foramina, 
and  consequently  did  not  open  them.  The  eyelids  were  tolerably  firmly 
closed,  so  that  only  a  small  portion  of  the  upper  lid  came  into  the  section, 


PLATE   III  41 

and  the  lower  remained  untouched.  The  globe  was  divided  almost  exactly 
in  the  middle.  The  saw  cut  the  upper  border  of  the  entrance  of  the  optic 
nerve  of  both  eyes.  In  the  orbits  it  was  necessary  to  remove  cautiously 
a  thin  layer  with  the  knife  in  order  to  expose  clearly  the  optic  nerves. 
These  show  a  slight  curve,  which  on  further  examination  is  seen  to  be 
associated  with  a  bending  downwards,  in  the  form  of  the  letter  $,  which 
is  their  normal  position  while  the  eye  is  at  rest.  This  fact  renders  it 
possible  that  considerable  traction  on  the  globe  may  exist  without  the  optic 
nerve  being  stretched  in  any  injurious  manner  in  the  various  movements 
of  the  eyes.  A  tension  of  the  optic  nerves  must  occur  unless  they  entered 
the  optic  foramina  in  this  curvilinear  manner.  It  may  be  left  unde- 
cided, and  for  further  investigation,  whether  by  a  stretching  of  the  sheath 
of  the  optic  nerve  a  lymph  motion  is  brought  about  in  its  course.  The 
researches  of  Schwalbe  have  established,  as  I  may  here  point  out,  that 
the  different  tensions  of  Tenon's  capsule  .during  the  action  of  the  muscles 
of  the  eyeball  may  perhaps  act  in  such  a  way.  It  is  certain  that  this 
relative  length  of  the  optic  nerve  is  necessary  to  ensure  the  position  of  the 
globe  when  the  eye  is  at  rest,  and  if  the  optic  nerve  were  tense  as  it  passed 
from  the  optic  foramen  to  the  globe  it  would  be  drawn  out  of  this  original 
position  by  the  constant  movements  of  the  eyeball. 

The  optic  nerves,  which  are  represented  rather  too  broad  in  the  plate, 
are  about  '16  of  an  inch  in  diameter.  Here  they  are  considerably  narrower 
than  when  they  are  within  the  skull.  In  the  latter  situation  they  are  from 
•2  inch  to  '24  inch  broad.  These  diameters,  however,  appear  at  first  sight 
to  be  equal  on  account  of  the  slight  length  of  the  nerves.  The  orbit  was 
not  opened  to  its  apex,  and  is,  moreover,  proportionally  small  even  for  a 
young  person's  skull.  The  length  of  the  nerve  from  the  optic  foramen  to 
its  entrance  into  the  globe  is,  according  to  Henle,  about  T2  inch,  according 
to  Soemmering  (' De  Oculorum  Sect,  horiz.,'  Gottingae,  1818)  l'4inch;  in 
the  present  plate  it  is  only  1'12  inch. 

On  the  other  hand,  it  shows  a  complete  agreement  with  the  statement 
of  Henle  that  the  centre  of  the  point  of  entrance  of  the  optic  nerve  is  '16 
nearer  the  middle  line  from  the  posterior  pole  of  the  axis  of  the  globe. 
Those  portions  of  the  globe  which  are  shown  in  the  preparation  require  no 

6 


42  PLATE   III 

further  explanation.  Their  symmetrical  form  appears  remarkable,  as, 
according  to  the  statement  of  Briiche,  some  considerable  want  of  symmetry 
exists  which  is  characterised  by  the  fact  that  the  equatorial  plane,  through 
the  iris,  lens,  and  ora  serrata,  converges  to  the  nasal  side.  The  globe, 
together  with  the  cornea,  exhibits  much  more  nearly  a  circle  in  a  section 
in  the  horizontal  meridian,  where  the  long  diameter  exceeds  the  transverse 
one  almost  imperceptibly. 

It  must,  however,  not  be  forgotten  that  preparations  such  as  the 
present  one  cannot  furnish  in  this  respect  any  absolute  standard.  The 
numerous  vessels  of  the  choroid  have,  as  is  known,  a  considerable  influence 
on  the  form  of  the  globe.  As  I  could  not  accurately  measure  the  pressure 
of  the  injection,  and  as  it  was  chiefly  calculated  to  throw  as  much  fluid 
as  possible  into  the  vessels  of  the  eye,  it  is  quite  possible  that  it  was 
considerably  more  powerful  than  it  would  be  under  natural  conditions ; 
great  pressure  in  the  vessels  of  the  eye  tends  to  approximate  the  form 
of  the  eyeball  to  that  of  a  sphere. 

It  is  to  be  further  remarked  that  freezing  does  not  seem  to  be  the  most 
suitable  method  of  hardening  the  eye.  Influences  are  thereby  exerted 
which  may  bring  about  variations  of  volume  in  the  watery  contents  of  the 
globe;  however,  I  know  of  no  other  method.  It  is  here  not  so  much 
a  question  of  determining  the  forms  and  position  of  individual  portions 
of  the  globe  as  it  is  of  representing  in  section  the  relations  of  the  eye  to 
the  orbit  and  to  the  other  portions  of  the  skull. 

The  dark  fissure  in  front  of  the  globe  represents  faithfully  the  expan- 
sion and  folding-in  of  the  conjunctival  sac.  Behind  are  the  attachments 
of  the  external  and  internal  recti,  which  are  inserted  into  the  globe  beyond 
its  axis  of  rotation — relations  which  are  not  represented  correctly  by 
Soemmering.  It  is  also  evident  that  the  internal  rectus  is  inserted  further 
forwards  than  the  external. 

At  the  inner  angle,  and  lying  on  the  lachrymal  bone,  is  the  section  of 
the  lachrymal  sac,  and  on  the  outer  angle  between  the  muscle  and  the  bone 
a  small  portion  of  the  lachrymal  gland. 

The  relation  of  Tenon's  capsule  cannot  be  represented  on  account  of  the 
small  size  of  the  plate ;  it  was  considered  that  a  multiplicity  of  lines  would 


PLATE   III  43 

interfere  with  clearness.      Moreover,    the  relations  of  this  membrane  are 
not  sufficiently  made  out. 

It  can  be  shown  that  this  membrane  is  in  relation  with  the  tarsal 
membrane,  and,  with  the  mass  of  fat  which  lies  behind  it  forms  a  sort  of 
cup,  into  which  the  globe  is  pressed  by  the  influence  of  the  external  air. 
Thus  the  eyeball  moves  somewhat  like  the  head  of  the  thigh  bone  in  its 
socket,  the  fluid  in  the  lymph  spaces  playing  the  part  of  the  synovia.  It 
is  not  yet  shown  how  the  capsule  of  Tenon  is,  continued  over  the  sheaths  of 
the  muscles  where  they  pass  back  through  it,  still  less  so  how  the  sheaths 
of  cellular  tissue  stand  in  connection  with  it.  Such  a  demonstration  would 
especially  be  of  practical  importance  as  regards  the  question  of  the  extent 
of  the  effusion  of  blood  in  the  orbit. 


PLATE   IV 

THIS  plate  does  not  represent  a  directly  transverse  plane  section,  but  an 
oblique  one.  In  order  to  bring  the  relation  of  the  ear  well  into  view  the 
section  is  taken  obliquely  backwards  and  upwards.  It  commenced  close 
under  the  nose,  and  has  involved  in  its  course  to  the  external  meatus  the 
inferior  turbinated  bone,  the  upper  portion  of  the  pharynx,  the  right 
Eustachian  tube,  the  tympanum  and  the  external  meatus,  and  passing  out 
through  the  pons  Varolii,  has  divided  the  upper  half  of  the  cerebellum 
and  the  posterior  lobe  of  the  cerebrum  above  the  external  occipital  protu- 
berance. The  preparation  was  made  from  the  body  of  a  young  man,  which 
presented  nothing  abnormal.  As  the  section  in  the  posterior  half  of  the 
left  side  passes  higher  than  in  the  right,  it  is  nearer  the  roof  of  the  left 
tympanum,  whilst  on  the  right  it  approaches  its  floor.  I  convinced  myself, 
however,  from  many  sections,  that  if  there  be  any  deviation  of  the  saw  from 
the  proper  direction,  it  is  not  possible  to  make  a  thoroughly  symmetrical 
preparation. 

In  this  plate  the  objects  of  chief  importance  are  the  relations  of  the  right 
organ  of  hearing,  the  section  of  which  has  been  so  fortunate,  that  not  only 
the  external  meatus  and  the  tympanum,  but  also  the  first  part  of  the 
Eustachian  tube  as  well,  have  been  divided.  I  was  never  again  able  to 
obtain  the  parts  together  to  such  an  extent,  although  I  made  more  than 
twelve  sections  in  the  same  direction.  Owing  to  individual  variations 
in  the  base  of  the  skull  in  the  direction  of  the  Eustachian  tube,  it  is  impos- 
sible to  give  any  exact  definitions  for  making  such  a  section. 

As  the  chief  points  of  interest  lie  in  the  upper  half  of  the  section,  it 
will  be  represented  instead  of  the  lower  half  as  in  preceding  plates ;  conse- 
quently one  looks  from  below  upwards  into  the  skull,  and  the  parts  lying 
on  the  right  side  are  really  those  of  the  left  side  and  vice  versa.  In 


Tab.  IV. 


PLATE   IV  45 

describing  the  individual  organs,  then,  of  the  left  ear,  the  left  nasal  cavity, 
and  so  on,  the  right  side  of  the  plate  must  be  consulted. 

The  upper  half  of  the  external  meatus,  the  relations  of  the  cartilaginous, 
integumentary,  and  bony  parts  of  the  right  ear  are  seen.  The  connections 
of  the  cartilaginous  portion  of  the  Eustachian  tube  with  the  cartilage  of 
the  pinna,  and  the  fissures  of  the  external  meatus  appear  as  gaps  between 
the  cartilaginous  rings. 

By  this  disposition  a  large  amount  of  passive  motion  is  allowed  at  the 
entrance  to  the  ear,  which  is  noticeable  equally  in  the  movements  of 
mastication  and  in  the  contractions  of  the  pinna.  By  drawing  back  the  ear 
the  curve  of  the  meatus  is  diminished  and  the  examination  of  the  membrana 
tympani  rendered  more  readily  accessible. 

It  is  worth  noticing  that  the  curvature  of  the  external  ineatus  is  not  so 
abrupt  as  one  might  imagine  from  the  examination  of  soft  preparations  or 
plates. 

After  examination  of  the  living  body  as  well  as  Pirogoffs  plates  (a  a  0, 
fasc.  i,  Tab.  6)  which  also  were  prepared  from  frozen  bodies,  and  in  spite  of 
the  various  differences  which  in  this  respect  the  external  meatus  offers,  I  must 
admit  that  the  parts  seen  in  the  section  of  a  body  not  thoroughly  hardened, 
vary  materially  with  their  original  position.  It  is  well  known  that  this 
canal  is  curved  from  before  backwards  and  from  above  downwards,  and 
is  thus  somewhat  serpentine  in  its  course.  Naturally,  the  relations  in  this 
section  could  not  be  represented  with  perfect  clearness,  although  it  will 
be  seen  from  the  stronger  shading  of  the  internal  parts,  that  the  upper  wall 
of  the  canal  rises  backwards  and  somewhat  upwards,  and  consequently 
that  the  semi-canal  in  the  region  of  the  membrana  tympani  is  deeper  than 
it  is  wide  externally. 

The  membrana  tympani  has  been  divided  in  its  lower  half,  hence  the 
ossicles  are  not  interfered  with. 

The  direction  and  position  of  this  membrane  should  be  noticed,  as  it  lies 
in  a  plane  which  makes  a  very  acute  angle  with  the  horizontal,  and  also  the 
navel-shaped  retraction  towards  the  tympanum,  and  the  portion  of  the  malleus 
which  is  in  relation  with  it.  As  the  ossicles  of  hearing,  on  account  of 
their  small  size,  are  very  difficult  to  represent  accurately,  a  woodcut  is 


46  PLATE  IV 

introduced  at  the  end  of  this  chapter,  in  which  the  parts  are  enlarged 
three  times.  Deep  down  in  the  tympanum  passing  from  before  back- 
wards is  seen  a  bony  protuberance  which  belongs  to  the  semi-circular  and 
Fallopian  canals,  and  behind  the  stapes,  in  the  section  of  the  temporal 
bone,  is  shown  the  canal,  containing  the  facial  nerve.  This  marked 
"  cropping  up  "  of  this  canal  on  the  roof  of  the  cavity  of  the  tympanum  is 
characteristic  of  the  young  individual.  The  young  ear  is  especially  suitable 
for  the  study  of  the  organ.  In  the  middle  line  from  the  stapes  is  the 
vestibule.  The  cochlea  is  not  shown  as  it  lies  above  the  section. 

Internally  and  in  front  of  the  cavity  of  the  tympanum  is  the  internal 
carotid  artery,  shown  from  its  entrance  to  its  first  curvature,  and  subse- 
quently divided  transversely.  In  front  of  the  carotid  is  the  Eustachian 
canal,  flat  anteriorly,  and  passing  deep  down  posteriorly.  It  runs  conse- 
quently more  vertically  backwards  than  the  plane  of  section  passing  from 
the  nasal  to  the  auricular  aperture.  The  section  passes  through  its 
pharyngeal  opening,  laying  that  portion  of  its  canal  free,  but  not  its  bony 
portion.  Thus,  only  a  small  portion  of  the  lateral  tubal  cartilage  (Riidinger's 
hook)  is  divided  anteriorly,  whilst  a  long  strip  of  the  median  cartilage 
is  exposed.  Laterally  the  canal  exhibits  a  mucous  membrane  rich  in 
glands  and  cellular  tissue.  A  portion  of  the  tensor  palati  can  be  seen,  and 
its  origin  can  be  traced  backwards  to  the  spine  of  the  sphenoid.  No  portion 
of  the  levator  palati  is  shown,  as  the  section  passed  above  its  origin. 
It  has  been  repeatedly  proved  that  the  tensor  palati  is  at  the  same  time  a 
dilator  of  the  Eustachian  tube,  and  an  elevator  of  the  lateral  cartilage,  thus 
opening  the  canal. 

The  excellent  representation  of  the  Eustachian  tube  in  Riidinger's  atlas 
('  Atlas  des  menschlichen  Gehororganes,'  Miinchen,  1867)  should  be 
compared  with  this. 

The  projecting  lip  is  clearly  seen  where  the  middle  of  the  tube  stands 
out  at  a  point  about  '6  of  an  inch  from  the  posterior  wall  of  the  pharynx,  and 
behind  it  is  the  fossa  of  Rosenmiiller  (recessus  infundibuliformis  of  Tourtual). 

The  mucous  membrane  of  the  pharynx  is  rich  in  glands,  and  is 
continuous  with  that  of  the  Eustachian  tube  and  nasal  cavities.  It  presents 
numerous  blind  crypts  and  depressions,  which  can  be  only  hinted  at  in  the 


PLATE   IV 


47 


Section  of  right  ear,  enlarged  three  times.     Seen  from  below. 

1.  Internal  carotid  artery.        2.  Vestibule.        3.  Facial  nerve.        4.  Corda  tympani. 
5.  Stapedius.        6.  Tensor  tympani. 


48  PLATE   IV 

plate.     The  mucous  membrane  has  fallen  into  the  section  at  the  point  where 
it  passes  over  to  the  roof  of  the  pharynx,  above  the  rectus  capitis  anticus. 

From  the  relative  position  of  the  Eustachian  tube  to  the  pterygoid 
process  and  inferior  turbinated  bone,  it  is  evident  that  oedema  of  the 
mucous  membrane  may  easily  close  up  its  opening.  Such  a  swelling  may 
happen  from  cold,  and  nasal  polypi  are  often  the  cause  of  difficulty  of 
hearing. 

As  regards  the  left  ear  there  is  little  to  say,  as  the  saw  passed  at  a 
considerably  higher  level  than  on  the  right  side.  The  cavity  of  the 
tympanum  is  laid  open  nearer  its  roof,  and  in  front  of  its  connection 
with  the  posterior  portion  of  the  Eustachian  tube,  at  the  middle  of  which  a 
bristle  has  been  introduced  into  the  canal  for  the  tensor  tympani.  Further 
forward  is  the  upper  half  of  the  cartilaginous  part  of  the  canal.  By  the 
laying  open  of  the  left  meatus  auditorius  internus,  the  auditory  nerve 
is  well  shown.  That  portion  of  the  nerve  which  goes  to  the  cochlea 
is  divided,  while  the  vestibular  nerve  passes  with  the  facial  through  the 
superior  fovea  (and  in  the  plate  disappears  deep  down).  The  section  of  the 
cochlea,  the  direction  of  its  base  to  the  meatus,  and  the  exposed  vestibule 
are  clearly  seen,  and  agree  with  Riidinger's  statements. 

There  is  nothing  to  add  as  regards  the  brain.  The  pons  Varolii  in 
section  shows  the  fibres  of  the  pyramid  passing  through  it.  The  anterior 
portion  passing  from  the  fourth  ventricle  to  the  aqueduct  of  Sylvius  is  met 
with ;  behind  it  is  a  part  of  the  vermiform  process. 

As  the  section  has  passed  through  the  skull  above  the  jugular  foramen, 
but  very  little  of  the  internal  jugular  vein  and  eighth  pair  of  nerves  are 
seen. 

On  the  anterior  border  of  the  pons  Varolii  are  the  divided  fibres  of 
the  sixth  nerve.  The  third  division  of  the  fifth  is  met  with  on  both  sides, 
just  below  the  foramen  ovale. 

The  branches  of  the  second  division  of  the  fifth  lying  in  the  section  are 
the  palatine,  which  lie  below  the  spheno-palatine  foramen,  and  the  dental 
branch  which  is  on  the  maxillary  tubercle. 

The  other  structures  and  tissues  on  the  plate  will  be  alluded  to  indi- 
vidually. 


Tah.V 


PLATE    V 

THIS  plate  and  Nos.  6,  7,  and  8,  are  made  from  sections  of  one  and  the 
same  body.  The  region  of  the  neck  was  cut  in  five  series  of  planes  of  which 
the  upper  surface  of  each  is  represented  and  analysed,  it  is  viewed  from 
above  downwards.  The  right  side  of  the  drawing  is  the  right  side  of 
the  preparation.  Owing  to  this  cutting  into  planes,  the  explanation  of  the 
individual  outlines  becomes  considerably  more  difficult  than  had  the 
sections  been  made  on  different  bodies.  By  making  very  thin  sections  the 
arrangement  of  the  muscles  of  the  nape  of  the  neck  were  very  difficult 
of  definition.  On  the  other  hand,  this  proceeding  affords  the  great 
advantage  that  the  under  surface  of  each  section  fits  exactly  on  the 
upper  surface  of  the  one  next  following  it,  and  also  that  the  separate 
organs,  such  as  the  thyroid  body  and  larynx,  which  show-  pretty  con- 
siderable individual  differences  with  reference  to  size  and  position,  can 
be  analysed  by  transverse  sections  which  mutually  correspond.  The  body, 
which  was  of  fine  proportions  and  perfectly  normal,  was  quite  fresh,  and 
was  about  twenty-five  years  of  age.  The  muscular  development  was  good. 
After  the  arteries  had  been  injected,  the  trunk,  from  which  the  lower 
extremities  were  removed,  was  frozen  in  the  usual  manner,  with  the  arms 
close  to  the  side,  and  prepared  as  has  been  before  described. 

In  consequence  of  the  great  muscular  development  the  shoulders  were 
very  high,  and  therefore  the  neck  appears  to  be  comparatively  short.  It  is 
not,  then,  to  be  wondered  at  that  sections  at  the  level  of  corresponding 
vertebrae  in  respect  to  the  region  of  the  shoulder,  differ  from  those  represented 
by  Pirogoff  (fasc.  i,  tab.  ii),  which  were  made  from  a  person  less  thoroughly 
developed. 

Fig.  1  corresponds  nearly  with  Pirogoff  (fasc.  i,  tab.  Ix,  fig.  1),  and 

7 


50  PLATE   V 

Henke  (taf.  Ixx,  fig.  2).  The  section  passes  through  the  mouth  and  runs 
somewhat  above  the  level  of  the  teeth,  falling  upon  the  hard  palate  and  the 
lateral  masses  of  the  first  cervical  vertebra,  and  slices  off  a  thin  lamina 
of  the  cerebellum  on  the  posterior  edge  of  the  foramen  magnum.  It  is 
seen  on  comparing  it  with  Plate  I  that  the  section  passes  obliquely 
backwards  and  upwards,,  from  the  head  being  bent  somewhat  backward 
in  the  recumbent  position  of  the  body.  This  relation  must  be  borne 
in  mind  in  observations  on  the  living  body.  In  the  normal  upright 
position  of  the  body  a  plane  section  through  the  level  of  the  teeth  would 
pass  through  the  second  cervical  vertebra,  and  would  not  touch  the  skull 

at  all. 

After  cleansing  the  preparation  it  appeared  that  a  small  portion  of  the 
dorsum  of  the  tongue  also  was  sliced  off  with  the  crowns  of  the  upper 
row  of  teeth.  The  apex  of  the  tongue  remained  just  behind  the  teeth. 
Posteriorly  the  section  had  passed  1'5  in.  from  the  foramen  caecum.  The 
papillae  which  are  seen  on  the  posterior  portion  of  the  section  correspond 
to  the  middle  of  the  tongue.  In  the  middle  line  from  before  backwards 
is  the  septum  linguae,  from  which  the  fibres  pass  to  both  sides  of 
the  transverse  muscles;  in  the  posterior  third  the  upper  longitudinal 
fibres  are  seen.  Behind  the  back  of  the  tongue  the  uvula  is  retained  in 
its  entire  length,  as  the  section  passed  through  the  soft  palate  a  quarter  of 
an  inch  above  its  root,  where  the  pillars  of  the  fauces  meet.  The  upper 
portion  only  of  the  tonsil  is  divided.  In  front  of  it,  and  behind  the  glands 
of  the  soft  palate,  lie  some  muscular  fibres  which  pass  transversely  upwards, 
belonging  to  the  upper  border  of  the  palato-glossus,  which  is  embedded 
in  the  anterior  pillar  of  the  fauces.  The  azygos  uvulae  is  also  seen. 
Behind  the  tonsil  and  in  relation  with  it  is  the  palato-pharyngeus,  which 
forms  the  posterior  pillar  of  the  fauces.  The  accurate  division  of  the 
muscles  cannot  be  defined,  nevertheless  it  appears  as  if  the  transversely 
divided  bundle  of  muscular  fibre  behind  the  tonsil  (especially  the 
left),  belongs  to  the  levator  palati.  There  is  no  portion  of  the  tensor 
palati  seen  since  the  section  passed  below  the  hamular  process.  A 
portion  of  the  superior  constrictor  of  the  pharynx  is  very  well  shown  in 
connection  with  the  lower  jaw  and  the  buccinator. 


PLATE   Y  51 

Within  this  muscular  zone  is  the  cavity  of  the  pharynx.  This  space 
is  often  thought  to  be  larger  because  it  is  observed  on  the  living 
body  in  an  oblique  direction,  through  the  posterior  palatine  arch  ;  in 
a  vertical  section  made  on  soft  preparations  the  interval  between  the 
uvula  and  the  posterior  wall  of  the  pharynx  is  generally  represented  as 
far  too  large.  In  the  operation  of  staphyloraphy  one  is  often  disagree- 
ably surprised  at  the  narrowness  of  the  locality,  and  must  resort  to  some 
one  of  the  ingenious  needles  which  have  been  invented  on  account  of  this 
want  of  room. 

Behind  the  muscular  tissue  of  the  pharynx  and  the  lax  cellular  tissue 
which  in  the  plate  is  represented  as  a  white  line,  lie  the  longi  colli  and 
recti  capitis  antici  majores,  and  further  outwards  on  the  transverse 
process  of  the  atlas  is  the  tendinous  origin  of  the  rectus  capitis  lateralis. 
The  position  of  the  internal  carotid  artery  is  of  the  utmost  importance  in 
operations  on  the  tonsil  and  pharynx.  It  is  seen  that  this  large  arterial 
trunk  lies  in  immediate  relation  with  the  muscular  tissue  of  the  pharynx ; 
its  pulsation  can  be  easily  felt  from  that  cavity  during  life,  and  deep 
incisions  in  this  region  should  not  be  made  without  the  greatest  caution. 

The  actual  position  of  the  artery  to  the  tonsil,  on  the  other  hand,  permits 
of  greater  freedom  in  extirpation  of  this  gland,  and  numerous  operations 
on  it  have  shown  that  Hyrtl's  apprehension  ('  Top.  Anat.,'  1,  380)  in  this 
respect  is  much  exaggerated.  Nevertheless  the  proximity  of  the  carotid 
must  be  especially  borne  in  mind,  even  in  the  forcible  dragging  of  the 
gland  from  its  bed,  but  from  the  benign  nature  of  most  of  the  tumours  of 
the  tonsil  there  is  no  necessity  for  endeavouring  to  remove  the  gland 
completely,  as  the  surgeon  may  be  thoroughly  satisfied  if  the  chief  mass  of 
the  growth  be  extirpated.  As  most  of  the  instruments  used  for  operations  in 
this  region  only  permit  of  a  levelling  and  not  of  an  extirpation  of  the  tonsil, 
there  is  a  sort  of  guarantee  against  wound  of  the  carotid.*  The  position 
of  the  inferior  dental  and  lingual  nerves  with  regard  to  the  lower  jaw,  is  well 

*  By  the  use  of  a  simple  curved  bistoury  and  vulsellum  forceps  the  tonsil  can  be  more  readily 
and  easily  removed  than  by  any  other  method,  and  the  object  of  dragging  the  gland  forcibly  from 
its  bed  towards  the  mesial  line,  with  a  view  of  avoiding  any  chance  of  wounding  the  vessel,  can  be 
well  recognised  from  examining  the  plate. — TB. 


52  PLATE   V 

shown.    With  regard  to  the  latter  nerve  it  is  to  be  remarked  that  wounds  of 
it  in  clumsy  extraction  of  teeth  from  the  slipping  off  of  the  instrument  have 
often  occurred.      Its    division  in  the    mouth  in  neuralgia,   as  Eoser  has 
recommended,  is  thoroughly  practicable,  without  cutting  through  the  cheek. 
After  extraction  of  the  last  upper  molar  the  nerve  may  be  divided  with  a 
tenotome  on  the  ramus  of  the  jaw,  without  the  necessity  of  further  dis- 
section.     The  articulation  between  the  axis    and  atlas  is  such  that    the 
saw    has    entered    under    the    anterior    arch   of   the  atlas,    dividing   its 
odontoid  process,  and  has  met  the  occipital  bone  over  the  posterior  arch. 
The  powerful  transverse  ligament  of  the  atlas  passing  obliquely   behind 
the  odontoid  process,  is   separated  from    the  bone  by  a  bursa.     Further 
back  is  seen   the   broad   ligamentous   mass  of  the  lateral  axoid  ligament, 
which   terminates    on  the   body   of    the    axis,  and   which    partly   passes 
over  into   the   posterior  common  ligament.      I  have  been  unable  to  find 
in    this    preparation   the   synovial   membrane    described  by  Luschka    as 
existing  between  these  ligaments.      Unfortunately,  the  two  ligaments  are 
not  clearly  enough  defined  from  each  other  in  the  plate ;    the  lateral  por- 
tions   of  the   ligamentum   latum   are    represented  too    streaky.      On   the 
anterior   aspect  of  the  odontoid  process  lies  the  ligamentous  mass  filling 
up  the  space  between  the  bodies  of  the  axis  and  anterior  arch  of  the  atlas — 
the  deep  anterior  axo-atloid  ligament.    A  portion  of  this  ligament  is  met 
with  below  the  anterior  arch  of  the  atlas  ;    the   anterior  articular  cavity 
lies  above  the  section.      It  will  be  seen  from  the  breadth  of  the  ligamentous 
mass  that  the  position  of  the  odontoid  process  acts  as  a  safeguard  against 
powerful  strains,  and  that  the  lateral  masses  of  the  atlas  must  have  a  great 
expanse  in  order  to  afford  sufficient  attachments  for  such  strong  ligaments. 
The  mass  of  cellular  tissue  which  closes  up  the  space  between  the  posterior 
arch  of  the  atlas  and  the  occipital  bone  is  very  lax,  and  the  posterior 
atlanto-occipital  ligament,  which  is  cut  at  a  very  acute  angle,  takes  up  a 
considerable  space.      Immediately  beneath,  the  posterior  arch  of  the  atlas 
can  be  felt.     It  is  here  that  the  vertebral  artery  makes  its  way,  in  order  to 
perforate  the  dura  mater  further  internally,  and  it  thus  reaches  the  medulla 
oblongata.      The    artery    is    divided    three    times,     on    account    of    its 
curves.     The  first  section  is  in  the  vertebral  canal,  where  the  artery  passes 


PLATE   V  53 

vertically  upwards,  and  the  second  where  it  bends  backwards  after  the  com- 
pletion of  the  curve  as  an  arc  flattened  transversely  towards  the  middle  line. 

There  is  nothing  particular  to  observe  with  regard  to  the  section  of  the 
skull  and  the  small  lamina  of  cerebellum.  As  the  skull  was  divided  very 
superficially  the  prominences  appear  larger  than  they  really  are,  and  they  thus 
acquire  such  singular  forms.  The  muscles,  vessels,  and  nerves  of  this 
region  are  readily  recognised  in  the  plate,  and  require  no  particular 
remark.  The  occipital  artery  of  the  right  side  is  seen  through  a  consider- 
able portion  of  its  length.  It  arises  from  the  posterior  aspect  of  the 
external  carotid,  and  passing  at  first  vertically  upwards,  crosses  the  internal 
jugular  vein  to  reach  the  posterior  belly  of  the  digastric.  From  thence  it 
runs  horizontally  backwards  in  the  lateral  region  of  the  neck,  being  covered 
by  the  trachelo-mastoid  and  splenius.  Having  arrived  at  the  middle  edge 
of  the  splenius  it  pierces  the  upper  origin  of  the  trapezius  (cucullaris),  and 
then  runs  superficially  on  the  skull.  Very  little  of  this  vessel  is  to  be  seen 
on  the  left  side.  Between  the  splenius  and  the  occipital  bone  a  muscular 
branch  appears  passing  deeply  from  its  trunk. 

The  glosso-pharyngeal,  vagus,  spinal  accessory,  and  hypoglossal  nerves 
are  shown  in  the  plate. 

The  parotid  gland  is  of  especial  surgical  interest ;  it  is  enclosed  in  a 
dense  fascial  envelope  which  surrounds  it  on  all  sides,  sending  a  multitude 
of  septa  into  the  substance  of  the  gland,  which  account  for  the  tabulated 
appearance  which  it  presents  on  section.  As  the  fascia  lines  the  entire 
niche  in  which  the  parotid  is  imbedded,  there  is  not  only  a  demarcation 
between  it  and  the  internal  jugular  vein  (which  must  especially  be  considered 
in  the  extirpation  of  tumours  of  the  gland),  but  it  is  a  protection  to  the 
vagus,  spinal  accessory,  and  hypoglossal  nerves,  which  are  in  close  proximity. 
The  portion  of  the  fascia  which  is  most  strongly  developed  is  that  which 
covers  in  the  outer  aspect  of  the  gland.  This,  on  account  of  its  connection 
with  the  fascia  of  the  masseter,  is  called  fascia  rnasseterico-parotidea. 

In  consequence  of  this  arrangement  the  swelling  of  the  gland  from 
inflammation  is  limited  externally,  thus  the  tumour  presses  internally 
against  the  nerves  and  vessels. 

The  parotid  being  pierced  by  the  terminal  branches  of  the  external 


54  PLATE   V 

carotid  artery  and  the  posterior  facial  vein,  its  extirpation  without  wound- 
ing these  vessels  is  impracticable.  But  if  the  carotid,  as  shown  on  the 
right  side  of  this  preparation,  lies  so  peripherally  that  it  can  be  dug  out  of 
the  mass  of  gland  tissue,  an  operation  would  be  less  uncretain  in  its  result. 

On  account  of  the  numerous  anastomoses  of  the  arteries  in  the  skull 
it  is  of  little  use  to  attempt  to  arrest  haemorrhage  from  the  external 
carotid,  but  in  the  event  of  complete  extirpation  of  the  gland  it  would  be 
necessary  to  direct  one's  attention  especially  to  the  preservation  of  the 
internal  jugular  vein. 

Figure  2  represents  the  upper  surface  of  a  lamina  1*5  inch  thick,  which 
corresponds  with  the  under  surface  of  Plate  IV.  The  section  which  the 
plate  represents  has  passed  through  the  thyroid  notch  and  has  fallen  close 
on  the  upper  border  of  the  fifth  cervical  vertebra. 

As  the  section  passed  immediately  below  the  chin  and  lower  jaw,  the 
neck  would  be  divided  in  its  so-called  cylindrical  portion.  It  is  seen, 
however,  that  on  account  of  the  muscular  development  at  this  level  the 
natural  form  of  the  neck  is  not  an  exact  cylinder,  consequently  its  section  is 
not  a  circle,  but  is  a  pentagon. 

The  lateral  portion  of  the  trapezius  (cucullaris)  commences  im- 
mediately below  the  section,  consequently  the  plane  -of  section  is  enlarged, 
corresponding  with  the  anterior  curvature  of  the  cervical  spine.  The 
section  of  the  vertebra  lies  much  further  removed  from  the  side  of  the 
neck  than  one  would  expect.  In  the  accompanying  plate  the  body  of 
the  vertebra  lies  in  the  anterior  half  of  the  figure.  The  point  met  with 
in  the  section  of  the  vertebra  is  where  the  arch  springs  from  the  body, 
hence  the  lumen  of  the  spinal  canal  is  seen.  On  the  left  side  is  seen  the 
articular  process  of  the  sixth  cervical  vertebra,  and  from  this  point  we  can 
follow  the  course  of  the  sixth  cervical  nerve  behind  and.  to  the  outer  side 
of  the  vertebral  artery.  The  divided  nerve  seen  lying  in  the  bifurcation  of 
the  transverse  process  is  the  fifth  cervical. 

The  larynx  is  so  divided  that  the  vocal  cords  with  the  ventricle  of 
Morgagni  between  them  is  clearly  shown.  The  mucous  membrane  which 
lies  behind  the  divided  arytenoid  cartilages  is  here  singularly  rich  in 
glands. 


PLATE   Y  55 

In  the  section  also  are  seen  the  arytenoid  glands,  many  of  which 
are  embedded  on  the  inner  side  of  the  aryteno-epiglottidean  fold.  The 
thyro-arytenoideus  and  the  arytenoideus  are  divided  through  their  upper 
extremities.  From  the  arrangement  of  the  muscles,  the  resemblance  to  a 
sphincter  can  be  clearly  recognised.  Behind  this  layer  of  muscles  lies  the 
large  mass  of  glands  of  the  pharynx — the  middle  arytenoid  gland  of 
Luschka. 

The  common  carotid  artery  is  shown  exactly  in  the  position  which 
would  be  most  suitable  for  its  ligature ;  its  relations  should  be  carefully 
noticed.  It  is  at  the  spot  where  the  deviation  of  the  omo-hyoid  and 
sterno-cleido-mastoid  allows  of  a  ready  means  of  access. 

However  incompletely  the  relations  of  the  fasciae  in  such  a  plate  are 
rendered,  one  can  see  clearly  that  the  vessel  must  be  sought  on  the 
anterior  border  of  the  sterno-cleido-mastoid,  and  that  after  the  division  of 
the  hinder  portion  of  its  sheath  the  space  containing  the  great  vessels 
and  nerves  is  immediately  entered. 

In  front  of  the  artery  is  the  descendens  noni,  and  somewhat  behind  it 
is  the  internal  jugular  vein  between  the  vein  and  artery  is  the  vagus,  and 
behind  the  artery  is  the  sympathetic.  Inside  the  sheath  of  the  vessels  a 
layer  of  cellular  tissue  isolates  the  artery  from  the  vein  and  the  nerve. 
The  important  part  of  the  operation  consists  in  opening  the  sheath  of  the 
artery,  which  lies  immediately  in  front  of  the  scalenus  anticus  muscle.  If 
this  be  properly  done,  one  not  only  avoids  the  danger  of  wounding  the 
nerve,  but  the  vein  also  will  be  kept  at  a  distance.  After  opening  the 
sheath  the  vein  would  expand  enormously  and  cover  up  the  whole  field  of 
operation.* 

*  In  ligature  of  the  carotid  pressure  should  be  made  on  the  internal  jugular  vein  by  the  fingers 
of  an  assistant  both  above  and  below,  in  order  to  prevent  this  expansion  of  the  vessel  from 
interfering  with  the  operator's  movements. — TB. 


PLATE    VI 

THIS  plate  is  taken  from  a  section  of  the  same  body  as  the  last,  and  has 
been  prepared  in  the  usual  manner. 

The  section  passed  through  the  larynx,  and  should  properly  have  kept 
to  the  plane  of  the  lower  vocal  cords,  but  it  passed  above  them  in 
a  horizontal  direction,  and  fell  on  the  lower  half  of  the  sixth  cervical 
vertebra. 

The  body  has  a  peculiarly  well-arched  thorax,  and  owing  to  the  great 
muscular  development,  the  shoulders  are  high  up,  and  although  there  are 
the  normal  number  of  vertebra  the  neck  appears  short,  corresponding 
in  the  most  marked  degree  with  the  male  type  of  neck  formation.  Here 
again  the  section  does  not  show  a  circular  contour,  but  rather  a  pris- 
matic one.  It  is  easily  seen  that  this  is  owing,  to  a  great  extent,  to 
the  powerful  muscular  development  of  the  sterno-cleido-mastoids  and  the 
trapezii. 

As  the  section  has  not  passed  through  the  head  of  the  humerus,  but 
through  the  acromio-clavicular  articulation,  it  did  not  traverse  the  shoulders 
at  their  greatest  breadth,  but  at  the  junction  of  the  regions  of  the  neck  and 
shoulder.  Therefore  the  lateral  portions  of  the  plate  represent  only  the 
upper  portion  of  the  roundness  of  the  shoulder,  the  supplementary  parts  of 
which  will  be  shown  in  following  plates. 

The  slight  irregularity  noticed  in  the  edges  is  owing  to  loss  of  substance 
after  the  use  of  the  saw. 

In  the  female,  or  slightly  developed  male  subject,  the  lamina,  which  in 
this  case  was  about  *4  in.  thick,  would  have  taken  a  totally  different  form, 
as  the  position  of  the  shoulder  would  be  lower  in  the  so-called  cylindrical 


H 
< 


PLATE   VI  57 

portion  of  the  neck,  and  consequently  exhibit  no  lateral  expansion  in 
the  region  of  the  junction  of  the  shoulder  and  neck,  the  upper  surface 
of  such  a  section,  however,  would  offer  another  shape,  and  approximate 
more  to  the  circular.  Pirogoff's  plate  (fasc.  i,  tab.  x,  fig.  5)  should 
be  examined  in  order  to  prove  that  it  is  the  feebly-developed  muscular 
neck  which  takes  the  circular  form.  Pirogoff,  moreover,  says  that 
his  section  was  taken  from  an  emaciated  body ;  however,  I  maintained 
from  recent  sections  on  a  man  of  fifty  years  of  age  (such  as  is  repre- 
sented in  Tab.  ix  of  the  first  volume),  that  a  section  at  the  level  of  the 
sixth  cervical  vertebra  is  tolerably  round.  The  present  case  must  then 
be  regarded  as  typical  of  the  neck  of  a  young  powerful  male,  and  deviations 
towards  the  circular  form  on  the  living  body  are  to  be  referred  to  want 
of  muscular  development. 

Sections  on  unhardened  bodies  naturally  give  no  fixed  forms  cor- 
responding with  their  original  relations.  The  parts  yield  so  much 
on  bodies  which  have  been  frozen  and  subsequently  thawed  that  the 
neck  gradually  acquires  a  circular  shape.  This  may  very  likely  be  the 
reason  that  the  plates  of  Beraud  and  Nuhn,  which  represent  very 
similar  regions  of  the  neck,  differ  so  essentially  from  mine  as  regards 
external  form.  (Beraud's  plate  is  in  his  'Atlas  d'Anatomie  Chirur- 
gicale,'  Paris,  1862,  pi.  xxxvii.  Nuhn's  is  represented  by  Henle, 
4  Muskellehre,'  p.  131,  and  by  Henke,  '  Abl.  der  Topographischen  Anatomie,' 
taf.  Ixix.) 

As  to  individual  portions  of  the  present  plate  to  be  studied,  the  first  of 
all  is  the  larynx,  which  is  divided  close  below  the  vocal  cords  ;  anteriorly  is 
the  arc,  formed  by  the  section  of  the  thyroid  cartilage,  and  close  behind  it 
the  section  of  the  cricoid.  Of  the  arytenoid  cartilages  only  the  muscular 
processes  are  met  with,  and  nothing  is  seen  of  the  vocal  processes,  as  they 
lie  higher.  The  space  between  the  thyroid  and  cricoid  cartilages  is  filled 
up  with  the  thyro-artenoideus  and  crico-arytenoideus  lateralis.  On  the 
other  side  are  some  fasciculi  of  the  thyro-epiglottideus.  Behind  this 
and  on  the  anterior  surface  of  the  crico-arytenoidei  postici  lie  the  inferior 
laryngeal  nerve  and  artery. 

From  the  form  of  the  transversely  divided  trachea  it  will  be  observed 

8 


58  PLATE   VI 

that  the  section  does  not  pass  far  below  the  rima  glottidis,  and  that  the 
surface  of  the  cricoid  cartilage  is  divided  obliquely  forwards  and  down- 
wards. The  space  expands  still  wider  further  downwards,  and  changes  its 
laterally  compressed  form  for  that  of  a  cylinder,  as  far  as  to  the  point  where 
the  cricoid  cartilage  encloses  it  completely.  Finally,  in  the  trachea  it 
becomes  in  section  a  segment  of  a  circle. 

As  the  present  plate  offers  no  points  of  great  interest  as  regards  the 
relations  of  the  larynx,  I  have  made  on  a  preparation  hardened  in  alcohol, 
a  section  exactly  in  the  plane  of  the  vocal  cords  and  introduced  it  in  the 

accompanying  woodcut.     It  will  be  seen  that 
FIG.  11. 

the  processus  vocales  are  continuous  imme- 
diately with  the  elastic  fibres  of  the  vocal 
cords.  At  the  line  of  section,  which  is  not 
sharply  defined,  some  reticulated  cartilage 
exists.  In  front  the  vocal  cords  pass  into  a 
roll  of  connective  tissue  to  which  the  thyro- 
arytenoid  muscles  are  attached.  The  mucous 
membrane  on  the  vocal  cords  is  destitute  of 
ciliated  epithelium, 'and  is  stretching  tightly  over  and  is  firmly  attached 
to  them.  Beneath  the  mucous  membrane  the  glands  in  this  plane  lie 
in  the  angle  between  the  anterior  extremities  of  the  vocal  cords  and 
between  the  arytenoid  cartilages  posteriorly.  On  either  side  of  the 
vocal  cords  are  seen  the  two  cut  surfaces  of  the  thyro-arytenoidei,  of 
which  the  median  is  shown  as  internal  and  the  lateral  as  external.  Still 
more  externally  are  the  cut  fibres  of  a  muscle  which  passes  partly  to  the 
thyroid  cartilage  and  partly  to  the  epiglottis,  the  thyro-aryteno-epiglottideus 
(Henle).  Behind  the  section  of  the  arytenoid  cartilage  the  arytenoideus 
is  seen  in  section  passing  across  from  one  cartilage  to  the  other. 
Referring  again  to  the  large  plate,  we  see  behind  the  cricoid  cartilage  and 
behind  the  section  of  the  crico-arytenoideus  posticus,  the  transverse  chink 
of  the  pharynx.  The  section  shows  it  empty,  therefore  its  anterior  and 
posterior  walls  are  in  contact  ;  behind  it  is  the  middle  portion  of  the 
inferior  constrictor  of  the  pharynx.  As  the  pharynx  lies  immediately 
upon  the  vertebrse,  and  the  longus  colli  and  recti  capitis  postici  majores, 


PLATE   VI  59 

the  space  required  by  the  morsel  of  food  in  passing  downwards  is  provided 
for  by  the  dragging  forward  of  the  anterior  wall  of  the  pharynx  and  the 
advancement  of  the  larynx.  The  larynx  is,  moreover,  lifted  in  swallowing. 
The  result  of  this  twofold  change  in  position  is  a  movement  of  the  larynx 
towards  the  chin,  which  can  be  easily  observed  during  the  act  of  deglu- 
tition. The  lax  cellular  tissue  which  lies  between  the  pharynx  and  the 
vertebrae  appears  in  the  section  as  a  narrow  border,  and  by  its  extra- 
ordinary looseness  it  permits  of  the  movements  of  the  pharynx  upon  the 
vertebrae.  But  it  is  of  such  a  nature  that  haemorrhage  into  it  would  cause 
great  distension.  This  condition  is,  moreover,  favorable  to  the  infiltration 
of  pus. 

Behind  the  pharynx  lies  the  section  of  the  sixth  cervical  vertebra, 
which  has  been  divided  in  its  lower  half.  As  the  section  fell  to  the  right 
side,  and  exactly  at  the  springing  of  its  arch,  a  clear  view  is  furnished  of  the 
lumen  of  the  spinal  canal,  which  has  the  form  of  an  equilateral  triangle, 
and  is  so  spacious  that  in  the  most  extensive  movements  of  the  cervical 
vertebrae  the  spinal  cord  has  free  room,  and  is  thoroughly  protected  from 
strain. 

The  relation  of  the  vertebra  to  the  surrounding  soft  parts  is  worthy  of 
notice,  inasmuch  as  it  appears  to  be  pushed  remarkably  forwards.  If  half 
the  diameter,  for  instance,  be  taken  from  before  backwards,  the  body  of 
the  vertebra  would  lie  completely  in  the  anterior  half  of  the  section. 
By  comparing  the  measurements  with  those  of  the  section  shown  in 
Plate  I,  and  also  in  the  other  figures,  it  is  seen  that  this  position  of  the 
vertebra  is  correct.  This  appearance  is  owing  to  the  cervical  curvature 
of  the  spinal  column.  The  distance  of  the  medulla  from  the  surface  of 
the  neck  on  the  living  body  is  usually  represented  as  far  too  slight.  Very 
similar  relations  will  be  found  in  Pirogoff  (fasc.  i,  tab.  iii,  fig.  2 ;  tab.  ii, 
fig.  1 ;  fasc.  i,  tab.  x,  fig.  66). 

As  the  body  of  the  vertebra  is  cut  through  near  its  lower  border,  its 
connection  with  the  transverse  process  is  clear.  The  vertebral  artery 
full  of  injection,  with  its  satellite  vein,  is  seen  in  the  bony  canal  on  either 
side.  On  the  left  side,  the  section  has  fallen  rather  deeper,  so  that  the 
canal  in  the  transverse  processes  is  closed  in  posteriorly  merely  by 


60  PLATE   VI 

ligamentous  tissue;  it  involves  also  the  superior  articular  process  of 
the  seventh  cervical  vertebra  and  its  joint  cavity.  Since  the  body  of  the 
sixth  cervical  vertebra  with  its  transverse  process  is  divided,  a  proper 
opportunity  is  afforded  of  examining  the  so-called  tubercle  of  Chassaignac 
and  its  relation  to  the  common  carotid  artery.  Among  surgeons  this 
process  is  known  as  Chassaignac's  tubercle,  and  is  considered,  according  to 
the  statements  of  authors,  to  be  a  most  valuable  landmark  in  seeking  the 
vessel,  in  cases  where  ligature  is  rendered  difficult  on  account  of  swelling  of 
the  tissues  or  the  presence  of  a  tumour. 

It  is  clearly  seen  that  the  anterior  of  the  tubercles  of  the  bifurcated 
transverse  process,  which  proceeds  from  the  side  of  the  body  of  the 
vertebra,  and  encloses  the  sixth  cervical  nerve,  is  a  direct  guide  to  the 
common  carotid  artery,  which  lies  immediately  upon  it.  Further,  with 
regard  to  this  tubercle,  it  has  a  morphological  importance  as  a  rudimentary 
rib,  and  is  correctly  called  the  eminentia  costaria,  jutting  out  more 
markedly  from  the  sixth  vertebra  than  from  any  of  the  others.  It 
can  be  readily  felt  in  the  living  body  if  gentle  pressure  be  made  on 
the  side  of  the  body  of  the  vertebra  upwards  towards  the  level  of  the 
larynx. 

Although  advantage  may  be  taken  of  the  presence  of  this  tubercle  in 
looking  for  the  vessel,  for  the  sake  of  demonstration,  and  of  making 
beginners  acquainted  with  its  locality,  still  it  is  not  necessary  for  surgeons 
of  experience  to  avail  themselves  of  such  a  means  of  assistance,  even  in 
complicated  cases.  If  the  vessel  has  to  be  ligatured  exactly  at  this  spot,  it 
is  better  to  make  the  usual  dissection  over  the  course  of  the  artery,  dividing 
layer  by  layer.  In  this  way  there  is  less  danger  of  wounding  important 
parts,  whilst  the  course  to  the  vessel  is  sure. 

The  position  of  the  vessels  is  denned  by  muscles  and  fasciae,  but  these  can 
be  easily  pushed  away  from  their  relations  with  the  bony  points.  When, 
however,  the  vessels  lie  in  bony  canals,  and  are  enclosed  as  fixedly  and 
unalterably  as  the  vertebral,  for  instance,  then  undoubtedly  the  determina- 
tion of  their  position  is  facilitated.  But,  on  the  other  hand,  the  means  of 
reaching  them  may  be  rendered  proportionately  difficult.  As,  however,  the 
carotid  can  be  easily  drawn  away  from  its  relation  to  Chassaignac's  tubercle, 


PLATE   VI  61 

this  prominence  as  a  means  of  assistance  is  not  directly  suitable  in  all  cases, 
as  is  already  proved  by  examination  of  the  normal  thyroid  body  (see  figure), 
the  upper  lobe  of  which  lies  between  the  artery  and  the  thyroid  cartilage. 
Swellings  of  this  gland  must  draw  the  artery  away  from  the  bony  promi- 
nence, but  they  do  not  permit  of  its  being  released  from  the  strong  fibrous 
sheath,  which  is  formed  by  the  investment  of  the  sterno-cleido-mastoid  and 
scalene  muscles,  and  of  the  gland  itself. 

From  a  section  which  I  made  at  a  similar  level  in  the  neck  on  a  well-frozen 
body  affected  with  goitre,  the  carotid  was  half  an  inch  external  to  the  tubercle 
in  question,  but  the  relations  of  the  muscle  and  fasciae  were  unaltered.  On  a 
closer  examination  of  the  plate  the  relation  of  the  fasciae  to  the  artery  will 
be  seen.  It  is  true  that  such  representations  are  insufficient ;  and  in  order 
to  make  clear  the  relations  of  all  the  fasciae  one  is  compelled  to  represent 
them  as  white  lines.  I  have  therefore  been  able  to  mark  out  satisfactorily 
the  coalescence  of  the  several  laminae.  Moreover,  actual  fasciae  cannot  be 
properly  distinguished  from  layers  of  cellular  tissue.  For  the  more 
accurate  relations  of  this  part  I  refer  to  the  works  of  Dittl,  Pirogoff, 
and  Henle.  I  may  add  that  the  contours  of  the  muscles  which  chiefly 
determine  the  arrangement  of  fasciae  are  sufficiently  accurately  represented 
in  the  preparation,  and  in  this  respect  furnish  trustworthy  points  of 
reference. 

Externally,  and  somewhat  behind  the  artery,  is  the  internal  jugular  vein, 
and  between  these  vessels  is  the  vagus,  which  in  ligature  of  the  artery  must 
be  carefully  protected  from  injury.  It  is  moist  safely  avoided,  if  after  divi- 
sion of  the  fibrous  sheath  a  fine  director  be  passed  through  the  cellular  tissue 
immediately  over  the  artery,  and  then  the  edges  of  the  fascia  pulled  aside 
with  two  pairs  of  forceps,  before  passing  the  ligature  needle.  By  this 
means  the  ligature  can  be  as  readily  applied,  either  from  without 
inwards  or  from  within  outwards.  Behind,  and  nearer  the  artery,  is 
the  sympathetic  nerve,  which  may  be  avoided  if  merely  the  old  rule  be 
followed  with  respect  to  the  vagus,  of  introducing  the  needle  from  without 
inwards.  Behind  the  vagus,  and  on  the  anterior  scalene  muscle,  lies  the 
phrenic  nerve. 

Behind  the  jugular  vein,  between   the  sterno-cleido-mastoid  and  the 


62  PLATE   VI 

middle  scalene  muscles,  are  the   supra-clavicular  twigs   from  the  fourth 
cervical  nerve. 

Between  the  anterior  and  middle  scalene  muscles  are  the  sections 
of  the  fifth  and  sixth  cervical  nerves,  which  are  figured  collectively  on  the 
plate  as  brachial  plexus,  so  as  not  to  disturb  the  detail  of  the  clearness 
of  the  drawings.  The  seventh  cervical  nerve  comes  off  from  the  spinal 
cord  in  the  vertebral  canal,  and  takes  a  direction  outwards  and  backwards 
behind  the  vertebral  artery. 

The  above-mentioned  figures  of  Nuhn  ('  Chirurg.  Anat.  Tafeln.,'  tat', 
iv,  fig.  2)  and  Beraud  ('  Atlas  d'Anat.  Chirurg.,' Plate  XXXVII,  fig.  2) 
should  be  compared,  as  the  question  to  be  proved  is  whether  in  these  plates 
of  sections  of  the  neck  the  natural  relations  are  represented,  since  they  show 
not  round  but  polygonal  contours.  There  is  one  word  to  be  added  here  on 
the  relations  of  this  section  with  respect  to  the  vertebra,  in  order  that  no 
misconception  may  arise : — Nuhn's  section  of  the  larynx  is  taken  almost 
at  the  same  level  as  mine,  whilst  in  Beraud's  nothing  of  the  trachea  below 
the  cricoid  cartilage  is  seen.  Both  authors  make  the  corresponding 
vertebra  the  fourth  cervical,  whereas  in  mine  the  sixth  is  shown.  One 
might  easily  conjecture,  therefore,  that  I  have  represented  a  wrong 
vertebra — an  error  which  may  be  easily  committed  if  one  has  been  already 
making  many  sections  of  the  neck.  I,  however,  expressly  state  that 
I  went  to  work  most  accurately  in  the  definition  of  the  vertebra,  and 
believe  that  I  have  made  no  mistake  in  the  accompanying  plate. 

By  comparing  the  vertical  sections  on  PI.  I  and  II,  as  Pirogoff  gives 
it,  the  fourth  cervical  vertebra  is  on  the  level  of  the  epiglottis,  and  the 
seventh  has  the  flat  surface  of  the  cricoid  cartilage  in  front  of  it,  which 
also  in  this  particular  agrees  with  my  plate.  It  cannot  be  disputed  that 
other  variations  in  this  respect  happen  to  the  extent  of  the  level  of  a  vertebra. 
These  variations  are  in  all  probability  occasioned  by  the  different  degree  of 
curvature  of  the  cervical  spine.  Nevertheless,  I  do  not  think  that  this 
change  in  position  can  be  extended  to  two  vertebrae,  and  I  maintain  that 
Beraud's  statement  that  the  fourth  cervical  vertebra  lies  deeper  than  the 
cricoid  cartilage  is  not  correct.  There  is  a  vertical  section  in  Beraud's 
atlas  (PI.  XXVIII,  fig.  2)  which  bears  out  my  statement.  Perhaps, 


PLATE  VI  63 

therefore,  the  parts  were  pushed  out  of  their  places  in  making  a  section  of 
a  soft  preparation. 

PirogofFs  transverse  sections  of  the  regions  of  the  neck  (fasc.  i, 
tab.  x)  coincide  with  my  account.  The  cricoid  cartilage  here  lies  in  front 
of  the  sixth  cervical  vertebra. 


PLATE     VII 

THIS  plate  and  those  which  immediately  precede  and  succeed  it  are 
taken  from  one  and  the  same  body.  Here,  as  is  evident,  the  superior 
surface  is  represented. 

The  section,  commencing  immediately  below  the  larynx,  passes  through 
the  under  edge  of  the  cricoid  cartilage,  and  involves  the  lateral  lobes  of 
the  thyroid  body,  the  under  surface  of  the  seventh  cervical  vertebra,  and  a 
portion  of  the  intervertebral  fibro-cartilage.  It  terminates  at  the  level  of 
the  articulation  between  the  acromion  and  clavicle.  As  can  be  verified  by 
measurement,  the  lateral  halves  are  of  equal  length,  and  there  is  consider- 
able symmetry  in  the  arrangement  of  the  individual  portions,  so  that  the 
track  of  the  saw  is  exactly  horizontal,  and  yet  there  are  many  differences  on 
the  two  sides  of  the  section.  On  the  right  side  the  part  between  the  clavicle 
and  acromion  is  opened,  and  a  portion  of  the  muscular  mass  of  the  serratus 
magnus  crops  up  from  the  scapula ;  the  head  of  the  first  rib  is  also  plain. 
On  the  left  side  the  section  passes  beneath  the  articulation  between  the 
clavicle  and  acromion,  and  ne'ither  the  rib  nor  the  angle  of  scapula  can  be 
seen.  It  will  be  observed,  then,  that  in  normal  and  faultlessly  formed 
bodies  deviations  from  lateral  symmetry  may  occur,  a  fact  which  does  not 
permit  representations  of  sections  of  one  half  of  the  body  only  being  made. 

As  the  section  passed  through  the  point  of  junction  of  the  cervical  with 
the  dorsal  vertebrae,  it  represents  the  area  between  the  back  and  the 
neck.  In  front  of  the  vertebra  the  section  keeps  completely  within  the 
region  of  the  neck  which  descends  lower  down  in  front  than  it  does  behind. 
The  clavicle  can  be  observed  in  considerable  length  through  the  integu- 
ment. 

This  relation  must  be  borne  in  mind  in  examining    deep-seated  gun- 


c- 

'** 
w 


PLATE   VII  65 

shot  or  punctured  wounds  in  this  region.  Students  and  beginners  espe- 
cially are  liable  to  look  for  the  highest  of  the  dorsal  vertebrae  much 
deeper  in  the  neck  than  at  the  lower  border  of  the  larynx.  Of  the  bony 
portion  of  the  vertebral  column  here  seen  we  have  the  under  surface  of  the 
body  of  the  seventh  cervical  vertebra,  and  its  long  spinous  process ;  this 
can  be  readily  felt  through  the  integument,  and  is  useful  as  a  commencing 
point  for  counting  the  dorsal  vertebrae.  To  this  vertebra  belong  the 
sections  of  the  divided  articular  process.  In  front  lie  the  articular  and 
transverse  processes  of  the  first  dorsal  vertebra,  and  on  the  right  side  juts 
out  the  head  of  the  first  rib. 

In  front  of  the  spinal  column  on  either  side  of  the  median  line  is  the 
longus  colli,  and  close  beside  it  on  the  transverse  process  is  the  scalenus 
anticus.  The  latter  muscle  is  separated  from  the  scalenus  medius  by  the 
transverse  section  of  the  brachial  plexus,  which  is  formed  by  the  anterior 
branches  of  the  last  cervical  and  first  dorsal  nerves ;  the  posterior  branches 
are  not  clearly  seen  in  the  preparation.  On  the  anterior  surface  of  the 
anterior  scalenus  is  shown  the  phrenic  nerve. 

Between  the  longus  colli  and  scalenus  anticus  lies  the  vertebral  artery 
with  its  vein,  which  have  been  divided  on  their  way  to  the  vertebral 
canal ;  and  immediately  in  front  of  the  vein  on  the  right  side  is  the  inferior 
cervical  ganglion  of  the  sympathetic.  On  the  left  side  the  sympathetic  lies 
between  the  scalenus  and  the  carotid,  and  a  branch  of  the  inferior  thyroid 
artery  is  to  be  seen  on  the  inner  side. 

On  the  front  of  the  spine  is  the  trachea,  which  passes  obliquely  down- 
wards and  backwards,  and  its  section  shows  the  rest  of  the  cricoid  carti- 
lage. Posteriorly  the  inferior  constrictor  of  the  pharynx  indicates  the 
position  of  the  commencement  of  the  oesophagus,  and  as  this  canal  is 
empty,  its  anterior  and  posterior  walls  are  closely  approximated.  Plate 
VIII,  which  is  taken  at  the  level  of  the  first  dorsal  vertebra,  shows  that 
the  gullet  deviates  considerably  towards  the  left  side. 

Between  the  trachea  and  oesophagus  on  either  side  is  seen  the  recurrent 
laryngeal  nerve,  and  more  externally  are  the  lateral  lobes  of  the  thyroid 
body.  Just  at  this  point  all  the  four  arteries  of  the  gland  are  visible,  and 
one  can  easily  appreciate  the  difficulty  of  applying  a  ligature  to  them.  The 

9 


66  PLATE   VII 

superior  thyroid  artery  has  already  entered  the  anterior  portion  of  the 
gland,  and  the  inferior  thyroid  is  seen  external  to  it.  .On  the  right  side, 
between  the  carotid  and  the  deep  muscles  of  the  neck,  are  two  large  divided 
vessels  which  belong  to  the  inferior  thyroid  artery,  which  springs  from  the 
subclavian,  passes  for  a  while  upwards  in  order  to  curve  behind  the  carotid, 
and  then  again  downwards  so  as  to  reach  the  thyroid  body.  The  vessel  is 
divided  just  below  the  loop,  so  that  both  its  ascending  and  descending 
portions  are  seen.  On  the  left  side  the  descending  portion  of  the  vessel 
has  already  given  off  branches. 

It  has  been  before  mentioned  that  in  such  sections  as  these  there  is 
very  great  difficulty  in  representing  fasciae,  consequently  all  the  finer 
laminse  lying  between  the  different  vessels  have  been  omitted.  The 
space,  however,  in  which  the  carotid,  internal  jugular  vein,  and  vagus 
nerve  are  enclosed  is  filled  up  with  cellular  tissue.  The  limits  of  this 
space,  as  a  whole,  are  accurately  shown,  and  it  can  be  understood  that  the 
sheath  of  the  vessel  is  formed  anteriorly  by  the  middle  portion  of  the  fascia 
of  the  neck  and  the  omo-hyoid,  internally  by  the  envelope  of  the  thyroid, 
posteriorly  by  the  lamina  covering  the  deep  muscles,  and  externally  by  the 
sheath  of  the  sterno-cleido-mastoid.  Inside  the  sheath,  externally  and 
somewhat  posteriorly,  lies  the  vein,  and  in  front,  between  the  artery  and 
the  vein,  is  the  vagus  nerve.  The  descendens  noni  lies  on  the  front  of  the 
sheath.  At  this  point  the  omo-hyoid  begins  to  cross  the  great  vessels  and 
to  become  tendinous,  as  is  well  seen  on  the  left  side. 

It  is  a  recognised  fact  that  the  operation  of  tracheotomy  should  be 
performed  by  preference  above  the  thyroid  body;  between  it  and  the  cricoid 
cartilage.  The  plate  shows  how  near  the  surface  the  trachea  lies  in 
this  region,  and  how  easy  an  operation  on  this  body  would  be  on  account 
of  the  normal  condition  of  the  thyroid  body  and  the  slight  development  of 
its  middle  portion.  As  shown  on  the  plate,  one  might  be  misled  by  the 
relations,  and  look  upon  it  as  advantageous  to  perform  the  operation  by  a 
single  stroke  of  the  knife ;  but  the  practitioner  is  warned  against  such  a 
proceeding ;  he  must  divide  the  tissues  cautiously  layer  by  layer,  inasmuch 
as  the  middle  portion  of  the  thyroid  body  may  widely  displace  the 
field  of  operation,  whilst  haemorrhage  from  it  is  very  difficult  to  arrest. 


PLATE   VII  67 

The  muscular  masses  which  compose  the  posterior  half  of  the  central 
part  of  the  plate  may  be  thoroughly  analysed,  and  they  are  suffi- 
ciently distinguishable  from  the  references.  It  should  be  here  observed 
that  on  the  left  side  the  section  has  passed  above  the  serratus  magnus, 
whereas  on  the  right  side  its  upper  edge  only  is  involved,  and  is  in  such 
close  relation  with  the  levator  anguli  scapulas  that  no  clear  line  of  demar- 
cation can  be  shown.  On  the  left  side,  in  the  separation  between  the 
levator  anguli  scapulas  and  the  trapezius  (cucullaris),  and  over  the  upper 
border  of  the  serratus  magnus,  lies  the  transversalis  colli  artery,  which  is 
divided  through  its  curve.  Its  course  is  clearly  shown  from  the  outer  side 
of  the  scalenus  medius,  and  its  relation  to  the  superficial  cervical  artery ; 
up  to  this  point  it  applies  itself  posteriorly  to  the  trapezius  and  levator 
anguli  scapulas,  in  order  to  terminate  in  the  region  of  the  angle  of  the 
scapula ;  on  the  right  side  this  vessel  is  seen  merely  in  section.  The 
trapezius  forms  the  largest  surface  of  the  section  and  is  divided  just  at 
the  point  of  its  fan-shaped  expansion.  The  posterior  fibres  run  more 
transversely  to  the  acromion  and  acromial  end  of  the  clavicle,  and  are 
therefore  cut  parallel  to  their  course;  the  mass  of  fibres  lying  on  the 
anterior  border  are  more  perpendicular  to  the  middle  portion  of  the  clavicle, 
and  are  divided  almost  transversely.  The  spinal  accessory  nerve  is  shown 
in  this  muscle. 


THIS  plate  represents  the  upper  surface  of  the  last  section  made  from 
an  uninjected  body,  which  has  also  afforded  material  for  the  previous 
plates ;  it  is  therefore  unnecessary  to  mention  anything  further  with 
regard  to  this  body,  as  the  essentials  will  be  found  with  the  explanation  of 
Plate  V. 

The  section  is  so  made  that  it  passes  directly  through  both  subclavian 
arteries  at  the  level  of  the  arches  which  they  describe  over  the  cupola  of  the 
lung,  and  very  fortunately  the  trunk  of  the  left  subclavian  artery  remains 
intact ;  whilst  that  of  the  right  side  is  divided  together  with  that  portion 
of  the  lung  which  lies  immediately  beneath  it.  It  extends  moreover  to  the 
level  of  the  isthmus  of  the  thyroid  body,  to  the  lower  edge  of  the  first 
dorsal  vertebra,  and  to  the  coracoid  process  of  the  humerus  above  the 
tuberosities.  One  consequence  of  the  high  position  of  the  shoulders  of 
this  individual  is,  that  the  lateral  portions  of  the  shoulder- joint  are  seen 
in  this  section,  whilst  in  the  case  of  less  powerfully  developed  bodies 
they  are  not  met  with  till  the  level  of  the  sterno -clavicular  articulation  is 
reached. 

With  regard  to  the  relations  of  the  spinal  column,  we  first  notice  a 
small  portion  of  the  body  of  the  under  surface  of  the  first  dorsal  vertebra, 
behind  it  the  connexion  between  it  and  the  second,  which  in  consequence 
of  the  curvature  of  the  spinal  column  has  been  sawn  through  obliquely. 
Small  portions  of  the  transverse  processes  of  the  second  dorsal  vertebra 
appear  behind  the  intervertebral  substance.  The  second  ribs  are  seen 
attached  to  these  processes  and  also  to  the  bodies  of  the  vertebra.  In 
the  mass  of  muscle  in  front  of  them  lie  the  first  ribs  in  section.  Nothing 
is  seen  of  the  sternum  and  the  sternal  end  of  the  clavicle,  since  these 


H 

P 


PLATE   YIII  69 

parts  lie  considerably  deeper,  as  is  shown  by  an  examination  of  the  thyroid 
body.     The  section  of  the  clavicles  passes  through  their  middle,  and  the 
subclavian  muscles   are  readily  seen.     The   upper   portion   of  the   thorax 
is  opened  by  the  section,  which  also  implicates  the  region  of  the  neck  in 
front.      Hence  it  is  impossible  to  determine  by  means  of  a  horizontal  plane 
where  the  region  of  the  neck  terminates  and  where  that  of  the  thorax  com- 
mences, but  the  boundary  must  be  carried  obliquely  backwards,  and  even 
then  the  neck  may  be  said  to  lie  not  only  above  the  thorax  but  partially  in 
front  of  it.      Consequently  it  cannot  then  be  wondered  at  that  wounds 
penetrating  the  neck  horizontally  above  the  clavicle  frequently  involve  the 
lung,  and  this  fact  must  he  kept  in  view  in  the  examination  and  diagnosis  of 
the  course  of  stabs  or  gunshot  wounds  of  the  lower  region  of  the  neck.     As 
the  left  lung  is  clearly  seen  through  its  exposed  and  uninjured  pleura,  whilst 
the  right  lung  and  the  subclavian  artery  are  divided,  one  might  perhaps 
imagine  that  the  saw  had  been  depressed  on  the  right  side ;  this,  however, 
was  not  the  case.     Although  the  horizontal  plane  was  adhered  to  as  accu- 
rately as  possible,  still  the  head  of  the  right  humerus  has  been  divided  at  a 
considerably  higher  level  than  the  left.     We  might  suppose,  therefore,  that 
in  this   body   the  right  lung  attains  a  higher  level  than   the  left.     This 
difference  is  clearly  seen  in  the  plate,  and  as  it  occurs  in  the  case  of  a 
young  and  perfectly  formed  normal  subject,  it  is  obvious  that  this  dispo- 
sition is  of  importance  in  percussion  of  the  apex  of  the  lung.     One  would 
naturally  expect  in  a  young  muscular  individual  a .  fuller  percussion  note 
above  the  clavicle  on  the  riglit  side  than  on  the  left,  and  if  the  reverse  con- 
dition  should  present  itself  the  existence  of  some  abnormality  may  be 
expected. 

On  both  sides  of  the  muscular  masses  of  the  longus  colli,  between  it 
and  the  lung,  is  the  second  cervical  ganglion  of  the  sympathetic ;  in  front 
of  and  above  the  cupola  of  the  lung  is  the  subclavian  artery,  and  laterally 
appears  the  obliquely-divided  surface  of  the  brachial  plexus.  As  the  artery 
does  not  exceed  the  highest  level  of  the  apex  of  the  lung,  but  lies  more 
on  the  anterior  slope  of  the  pleura,  the  brachial  plexus  forms  a  sort  of 
niche  with  the  spinal  column  to  receive  the  absolute  apex  of  the  lung. 
On  the  left  side  especially  this  arrangement  is  well  seen. 


70  PLATE   VIII 

The  left  subclavian  artery  is  intact,  but  sections  of  two  of  its  branches 
are  represented.  The  inner  of  these  is  the  vertebral,  the  outer  the 
thyroid  axis.  In  front  the  superficial  cervical  artery  winds  round  the 
anterior  scalene  muscle  and  the  phrenic  nerve,  and  mounts  up  obliquely 
above  the  brachial  plexus  in  order  to  gain  the  nape  of  the  neck.  It 
has  been  divided  at  the  commencement  of  its  course,  and  immediately 
below;  the  posterior  belly  of  the  omo-hyoid  overlaps  it,  a  small  portion 
of  the  muscle  having  been  cut  off,  but  almost  the  whole  of  it  is  shown 
in  the  section  immediately  preceding.  On  the  hinder  border  of  the  sub- 
clavian are  the  openings  of  two  small  arteries  which  are  not  very  clearly 
defined.  The  transverse  cervical  artery,  the  extremity  of  which  is  seen 
in  the  preceding  plate,  sprang,  in  common  with  the  inferior  thyroid,  from 
the  large  trunk  in  the  mass  of  the  scalenus  anticus,  and  the  continuation 
of  its  trunk  (the  posterior  scapular)  is  seen  t<j  be  covered  by  the  rhom- 
boid muscle. 

The  supra-scapular  artery  lies  behind  the  subclavian,  and  is  again  seen 
near  the  coracoid  process,  behind  the  conoid  and  trapezoid  ligaments, 
whence  it  passes  towards  the  supra-scapular  notch.  It  runs  over  the  trans- 
verse ligament  of  the  scapula  to  the  supra-spinous  fossa,  whilst  the  accom- 
panying nerve  passes  below  the  ligament. 

The  section  has  removed  a  strip  of  the  upper  surface  of  the  right 
subclavian  artery,  and  at  the  inner  end  there  is  a  bulging  out  of  the 
wall  of  the  artery  corresponding  with  the  origin  of  the  thyroid  axis, 
and  indicating  the  point  of  origin  of  the  superficial  cervical  artery. 
Further  outwards,  between  the  subclavius  and  serratus  magnus  are  the 
supra-scapular  nerve  and  artery  to  which  we  have  already  alluded. 

On  comparing  the  subclavian  arteries  of  the  two  sides  it  is  evident 
that  on  account  of  the  higher  level  of  the  right  over  the  cupola  of  the 
lung,  that  the  first  portions  of  both  have  very  different  directions.  These 
differences  are  dependent  on  the  variation  of  origin  of  the  two  vessels. 
The  ascending  portion  of  the  left  subclavian  (from  the  aorta)  lies 
further  backwards,  and  is  in  relation  with  a  considerable  portion  of 
the  pleura,  whilst  the  right  passes  in  the  opposed  direction  of  the 
blood-stream,  forwards,  to  unite  with  the  common  carotid  to  form  the 


PLATE   VIII  71 

innominata.  The  portion  of  each  artery  here  shown  belongs  to  the 
middle  part  of  its  course.  The  direct  proximity  of  the  lung  and  pleura 
indicates  clearly  enough  the  danger  of  ligature  in  this  situation,  and 
all  cases  hitherto  undertaken  have  been  attended  with  unfortunate 
results. 

In  front  of  the  subclavian  artery  on  either  side  is  the  common  carotid, 
and  between  these  vessels  is  the  trunk  of  the  vertebral  and  deep  cer- 
vical veins ;  and  in  the  middle  line  is  the  long  cardiac  nerve. 

The  vertebral  vein  is  subject  to  many  variations.  Although  in  the 
vertebral  canal  it  is  generally  a  single  trunk,  it  may  form  a  plexus.  In 
rare  instances  it  joins  with  the  deep  cervical  vein,  and  passing  down 
behind  the  articular  process,  forms  a  trunk  which  receives  the  blood 
from  the  sinuses  in  the  canal.  It  has  also  many  variations  in  its  point 
of  termination,  the  most  frequent  of  which  is  in  the  commencement  of  the 
innominate  vein,  and  it  may  pass  down  hence  either  in  front  of  or  behind 
the  subclavian  artery. 

In  one  case,  on  the  left  side  of  the  body,  it  was  found  as  a  trunk 
in  the  vertebral  canal,  in  front  of  the  vertebral  artery,  and  at  its  point 
of  exit  from  the  canal  was  directed  forwards,  and  passed  over  the 
subclavian  artery  in  front  in  order  to  terminate  in  the  left  innomi- 
nate vein  near  the  junction  of  the  internal  jugular.  Thus  it  formed 
with  this  large  trunk,  on  the  inner  side  of  the  vertebral  artery,  a 
V,  in  which  lay  the  thoracic  duct  before  emptying  into  the  subclavian 
vein.* 

In  a  second  case  the  vertebral  vein  came  forwards  from  behind  the 
subclavian  artery,  between  it  and  the  pleura,  and  terminated  in  the 
lower  end  of  the  internal  jugular,  so  that  after  the  removal  of  the  pleura 
the  vessel  could  be  seen  lying  free,  and  crossing  the  subclavian  artery 
from  behind  forwards.  Into  the  horizontal  portion  of  the  vertebral, 
a  vein  opened  corresponding  to  the  deep  cervical,  in  front  of  the  sub- 
clavian artery.  On  the  right  side  of  the  body,  in  a  third  case,  it  passed 
behind  the  subclavian  artery,  whilst  on  the  left  it  passed  in  front  of  it, 

*  I  have  on  more  than  one  occasion  observed  the  thoracic  duct  to  terminate  in  the  lower  part 
of  the  vertebral  vein. — TE. 


72  PLATE  VIII 

and  in  a  fourth  case  it  passed  down  on  both  sides  of  the  body  in  front  of  the 
subclavian  artery. 

These  relations  are  important,  inasmuch  as  in  ligature  of  the  ascending 
portion  of  the  subclavian  artery  they  are  frequently  met  with,  and  care 
must  be  taken  to  avoid  them.  Directions  are  given  for  the  avoidance  of 
nerves  and  arteries,  but  no  notice  is  taken  of  the  vertebral  vein,  or 
of  the  thoracic  duct,  which  on  the  left  side  lie  close  up.  On  the  outer 
side  of  the  carotid,  immediately  behind  the  sterno-cleido-mastoid,  is 
the  internal  jugular  vein,  and  between  it  and  the  carotid,  the  vagus 
nerve. 

The  external  jugular  vein  is  seen  on  the  left  side,  between  the  clavicle 
and  omo-hyoid  muscle.  On  the  right  side  it  opens  into  the  divided  trans- 
versus  scapulas  vein.  The  subclavian  vein  is  not  seen  as  yet,  as  it  lies 
below  the  section. 

In  front  of  the  trachea  is  the  thyroid  body,  which  is  divided  directly 
through  its  isthmus.  It  appears  to  be  completely  normal,  both  as  regards 
structure  and  size,  which  in  this  country  (Saxony)  is  seldom  the  case, 
as  most  subjects  show  enlargement  of  this  gland. 

The  oesophagus  at  the  level  of  the  gland  begins  to  leave  the  mesial  line 
to  get  to  the  left  side. 

In  Plate  X,  which  gives  the  structures  at  the  level  of  the  sterno-clavicular 
articulations,  the  oesophagus  already  lies  to  the  left  side  of  the  trachea. 
Although  this  lateral  deviation  of  the  oesophagus  is  the  rule,  still  the  exact 
level  at  which  the  greatest  deflection  takes  place  appears  to  vary.  I 
find  this  lateral  position  complete  in  PirogofPs  atlas  (tab.  i,  fasc  ii),  in 
which  the  section  has  passed  between  the  first  and  second  dorsal  vertebras, 
as  in  Plate  VIII,  where  the  oesophagus  first  begins  to  leave  the  middle 
line. 

The  head  of  the  left  humerus  is  divided  nearly  in  its  middle,  and 
in  front  is  part  of  the  greater  tuberosity,  into  which  is  inserted  the 
tendon  of  the  infra-spinatus.  Under  this  tendon,  and  close  to  its 
insertion,  is  the  thinnest  part  of  the  capsular  ligament.  The  supra- 
spinatus,  the  mass  of  which  is  seen  between  the  two  bony  ridges  which 
belong  to  the  scapula,  is  divided  at  its  anterior  extremity,  at  the  point 


PLATE   VIII  73 

where  it  ascends  to  its  insertion  into  the  greater  tuberosity.  Its  tendon 
is  blended  with  the  fibrous  structures  on  the  anterior  surface  of  the 
articulation. 

The  deltoid  with  its  intermuscular  septa  is  well  developed,  and  between 
it  and  the  insertions  of  the  muscles  attached  to  the  greater  tuberosity  is  a 
bursa,  the  cavity  of  which  is  indicated  by  a  black  line. 

As  the  glenoid  cavity  has  been  divided  nearly  in  the  middle,  the  tendon 
of  the  long  head  of  the  biceps  lies  free  in  the  joint.  Beneath  it  was  found 
a  thin  fold  of  synovial  membrane,  but  higher  up  the  tendon  was  completely 
free.  •  On  the  anterior  surface  of  the  coracoid  process  are  the  tendinous 
origins  of  the  biceps  and  coraco-brachialis,  and  internal  to  them  the  fleshy 
mass  of  the  pectoralis  minor.  On  the  posterior  and  inner  side  of  this 
process  the  conoid  and  trapezoid  ligaments  are  seen  in  section.  The  head 
of  the  right  humerus  is  divided  considerably  higher  than  that  of  the  left, 
namely,  at  the  level  of  the  upper  border  of  the  glenoid  cavity.  In  conse- 
quence of  this  the  articular  cartilage  appears  completely  encrusting  the 
bone.  The  capsule  is  free  all  round,  and  the  tendon  of  the  long  head  of  the 
biceps  is  seen  coming  up  to  be  incorporated  with  the  glenoid  ligament. 

Too  much  must  not  be  expected  from  the  plate,  as  the  bundles  of  the 
tendinous  masses  can  be  only  represented  in  general.  The  individual 
fibres  of  the  tendon  of  the  infra-spinatus,  for  instance,  cannot  be  followed 
out  round  the  head  of  the  humerus.  They  become  lost  deeper  down  on 
the  greater  tuberosity,  and  are  intimately  blended  with  the  insertion  of  the 
supra-spinatus. 

If  the  section  in  this  plate  be  compared  with  Plate  IX  in  the  large 
coloured  atlas  (also  the  section  of  a  young  powerful  man)  as  well  as  with 
that  of  a  man  fifty  years  of  age,  its  massive  mould  would  be  evident. 

The  individual  layers  of  muscle  are  everywhere  broader,  although  the 
skeleton  itself  does  not  appear  larger  or  stronger. 

The  difference,  therefore,  between  the  longitudinal  and  horizontal 
measurements  does  not  show  itself  in  the  manner  which  one  would  be  led 
to  expect  from  a  superficial  examination.  For  though  the  lower  outline 
was  drawn  exactly  to  the  section  (and  therefore  closely  corresponds  with 
the  plane  in  Plate  IX  in  the  large  atlas),  the  breadth  of  the  shoulder  is 

10 


74  PLATE  VIII 

nearly  an  inch  more  than  in  the  old  man,  whereas  the  antero-posterior 
diameter  is  half  an  inch  more  in  the  old  than  in  the  young  man.  Plate  IX 
in  the  large  atlas  should  not  be  incorporated  with  the  series  of  the  plates, 
as  in  the  old  man  more  abnormalities  exist.  There  was  a  considerable 
enlargement  of  the  liver,  and  a  very  great  development  of  the  thyroid  body, 
so  that  the  relations  of  the  parts  in  the  neck  (as  seen  in  Plate  XXV)  are 
much  altered.  The  thyroid  gland  was  enlarged  below  and  on  the  left 
side,  so  as  to  encroach  on  a  portion  of  the  superior  aperture  of  the  thorax. 
It  also  pressed  the  left  subclavian  artery  inwards  and  backwards  upon 
the  cupola  of  the  lung ;  the  oesophagus  also  was  pushed  out  of  its  place 
against  the  trachea,  embedding  itself  between  it  and  the  vertebral  column. 
The  relation  of  the  carotid  artery  to  the  sixth  cervical  vertebra  has  been 
already  described,  and  it  has  been  stated  that  the  position  of  the  arteries 
is  to  be  defined  not  by  the  bone,  but  by  the  directions  of  the  muscles 
and  fasciae,  and  that  the  bony  prominences  alone  should  not  be  con- 
sidered of  value  as  landmarks  for  finding  the  arteries.  The  same  remark 
applies  to  the  veins,  nerves,  trachea,  and  oesophagus  in  the  region  of  the 
neck.  These  structures  are  so  freely  movable  in  the  anterior  region  of  the 
neck  that  the  movements  of  the  trunk  or  the  pressure  of  a  tumour  may 
materially  alter  their  position.  This  is  particularly  evident  in  Plate  IX 
in  the  larger  coloured  atlas ;  it  can  be  estimated  also  in  the  present  plate. 

Such  a  change  of  position  with  regard  to  the  skeleton  is  owing  to  the 
presence  of  the  loose  cellular  tissue  which  envelopes  these  structures. 
But  the  relation  of  these  important  structures  with  regard  to  the  muscles 
and  fasciae  is  constant,  and  consequently  if  an  operation  such  as  trache- 
otomy, oesophagotomy,  or  the  extirpation  of  a  tumour,  has  to  be  per- 
formed, the  surgeon  must  make  himself  well  acquainted  with  the  fasciae  and 
muscles. 


a 


PLATE    IX 

THIS  plate  represents  a  section  between  the  regions  of  the  neck  and 
thorax  of  a  man  twenty-two  years  of  age,  powerfully  built  and  perfectly 
normal. 

All  the  sections,  as  far  as  to  that  of  the  pelvis,  in  the  following  series 
have  been  made  from  this  subject. 

The  lamina  in  this  plate  was  about  1'4  inch  thick,  and  its  upper  surface 
is  shown,  so  that  the  body  is  viewed  from  above.  The  arteries  were 
injected.  The  section  passed  just  below  the  upper  border  of  the  manu- 
brium  sterni,  and  through  the  upper  margin  of  the  third  dorsal  vertebra, 
together  with  a  small  portion  of  its  underlying  cartilage. 

Close  to  the  sternum  lie  the  clavicles  in  section  and  their  interarticular 
fibro-cartilages.  Laterally,  near  the  sternal  ends  of  the  clavicles,  are 
the  sections  of  the  first  ribs,  behind  them  those  of  the  second,  and  further 
backwards  and  inwards  those  of  the  third.  These  last  are  not  quite 
symmetrically  divided,  in  consequence  of  the  somewhat  higher  level  of 
the  right  side  of  the  chest.  On  the  left  side  the  third  rib  exhibits  in  con- 
nection with  it  a  portion  of  the  transverse  process  of  the  vertebra  which 
articulates  with  it ;  whilst  on  the  right  side  merely  a  small  portion  of  the 
head  of  the  rib  is  shown. 

The  scapulae  are  divided  through  the  glenoid  cavities.  The  heads  of 
the  humeri  show  the  greater  tuberosities  and  the  lower  portion  of  their 
articular  surfaces. 

If  the  plate  which  in  the  large  coloured  atlas  is  figured  IX  be 
compared  with  this  (the  position  of  the  parts  in  the  man  of  fifty  years 
with  that  of  a  man  of  twenty-two  years),  it  will  be  seen,  that  in  the  former 


76  PLATE   IX 

instance  the  under  Surface  of  the  third  dorsal  vertebra  is  divided,  and  in 
the  latter  the  upper.  In  the  younger  subject,  also,  the  plane  of  section  has 
passed  nearly  an  entire  vertebra  higher,  yet  in  spite  of  this  the  sternum  is 
deeper. 

It  would  follow,  then,  that  although  the  section  was  perfectly  hori- 
zontal the  sternum  lies  higher  in  the  young  subject  than  in  the  old. 
If  the  transverse  and  antero-posterior  diameters  of  both  the  sections  be 
compared,  the  latter  diameter  is  seen  to  be  the  larger  in  the  old  man, 
whilst  the  transverse  diameter  is  less.  It  is  possible  that  the  enlarged 
thyroid  gland  invading  the  cavity  of  the  thorax  may  be  the  cause  of  this 
difference. 

By  comparison  of  the  shoulders,  we  observe  that  in  consequence 
of  the  extremely  powerful  muscular  development  they  stand  much  higher 
in  the  young  man ;  therefore  considerably  more  is  removed  by  the  saw. 
A  glance  at  the  large  surface  which  involves  the  pectoralis  major,  the 
deltoid,  and  the  subscapularis,  suffices  to  show  that  the  muscular  develop- 
ment has  been  great. 

The  anterior  contour  is  partly  owing  to  these  masses  of  muscle  and 
partly  to  the  different  attitude  of  the  shoulders.  It  may  be  that  the  older 
subject  was  frozen  with  the  arms  slightly  raised,  and  with  the  shoulders 
pushed  somewhat  backwards,  whereas  in  the  present  instance  the  arms 
were  laid  close  against  the  thorax. 

By  measuring  the  sections  it  is  shown  that  the  antero-posterior  and 
transverse  diameters  of  the  body  differ  but  little. 

The  transverse  diameter  in  this  plate  amounts  to  nearly  an  inch  more 
than  in  Plate  IX  in  the  coloured  atlas,  if  both  sections  be  reduced  to 
equal  scale,  since  the  bony  contours  are  more  regular.  In  the  middle 
portion  of  this  plate  the  position  of  the  vessels  and  nerves  is  more  intel- 
ligible than  on  the  section  of  the  body  of  the  older  individual,  owing  to  the 
changes  in  the  relative  position  of  the  parts  from  the  presence  of  the  goitre 
in  the  other  case. 

Behind  the  sternum  lie  the  sections  of  the  sterno-thyroids,  and  near 
them  and  behind  the  clavicles  are  the  sterno-hyoids.  In  front  of  the 
sternum  are  the  tendinous  origins  of  the  sterno-cleido-mastoids.  Further 


PLATE   IX  77 

in  behind  the  muscle,  the  sternum,  and  the  clavicles,  is  the  upper  por- 
tion of  the  thyroid  body.  It  is  separated  from  the  sterno-mastoid  by 
the  middle  layer  of  the  cervical  fascia.  Further  back  is  the  left  inno- 
minate vein,  which,  on  account  of  its  oblique  course  downwards  from 
left  to  right,  is  extensively  divided.  The  trunk  can  be  followed  towards 
the  right  side  as  far  as  the  lumen  of  a  vein,  which  is  the  inferior  thyroid 
vein  opening  vertically.  On  the  other  side  of  this  vein  the  trunk  lies 
more  deeply  and  is  no  longer  seen  through  the  cellular  tissue.  The 
isolated  right  innominate  vein  is  divided  transversely. 

On  examining  the  left  innominate  vein  two  small  openings  are  seen ; 
the  anterior  of  these  is  the  internal  mammary  vein,  and  the  posterior 
the  thoracic  duct.  The  duct  in  this  instance  opens  more  internally 
than  is  usual,  and  into  the  innominate  instead  of  into  the  subclavian 
vein  ;  and  it  may  be  followed  on  the  inner  pleural  surface  of  the  left  lung 
directly  backwards,  whence  it  bends  downwards,  applying  itself  along  the 
vertebral  column. 

On  the  right  side  behind  the  great  vein  are  a  series  of  four  large 
arteries,  which  pass  obliquely  towards  the  middle  line.  Commencing  from 
the  left  side  they  are,  the  left  subclavian,  the  left  vertebral  (which  in 
this  case  sprang  independently  from  the  aortic  arch),  the  left  carotid,  and 
the  innominate.  The  arch  of  the  aorta  is  immediately  below  the  plane  of 
section. 

Although  the  length  and  point  of  origin  of  the  innominate  artery 
are  liable  to  considerable  variations,  the  vessel,  nevertheless,  lies  so  close 
to  the  middle  line  that  it  should  be  searched  for  in  the  middle  line  of  the 
jugulo-tracheal  space,  as  Pirogoff  recommends.  After  researches  on  the 
dead  body,  I  have  convinced  myself  that  this  proceeding  is  the  surest  guide 
to  the  vessel. 

The  head  is  to  be  drawn  towards  the  left  side  and  the  right  shoulder 
depressed,  and  the  tissues  divided  as  far  as  the  group  of  muscles  coming 
from  the  hyoid  bone  and  larynx.  It  is  a  matter  of  importance  to  make  the 
incision  exactly  in  the  middle  line  between  both  sterno-thyroid  muscles, 
and  to  divide  the  dense  cervical  fascia  to  which  the  great  veins  are 
intimately  attached.  If  this  be  done  the  trunk  of  the  artery  in  the 


78  PLATE   IX 

loose  cellular  tissue  can  be  isolated  from  the  trachea,  and  the  ligature 
passed.  The  surgeon  must  remember  that  close  to  it  is  the  left  innomi- 
nate vein,  which  runs  obliquely  across  its  trunk,  and  that  on  the  right 
side  of  the  trunk,  as  is  shown  in  the  plate,  the  vagus  nerve  passes  down. 
The  vagus  in  this  case  was  met  with  below  the  point  of  origin  of  the 
recurrent  laryngeal  nerve ;  it  therefore  lies  further  back  than  it  does  higher 
up  in  its  course  on  the  left  side ;  the  recurrent  laryngeal  nerve  is  between 
the  oesophagus  and  trachea,  and  the  trunk  of  the  vagus  is  in  front  of  the 
subclavian  artery. 

From  the  position  of  the  innominate  artery  it  is  clear  that  burrowing 
of  pus  in  the  mediastinum  is  likely  to  follow  such  an  operation  as  its 
ligature,  whilst  the  relative  shortness  of  its  trunk  and  the  strong  pressure 
in  the  arch  of  the  aorta  are  serious  obstacles  in  the  way  of  the  formation  of 
a  resisting  thrombus.  It  is  therefore  obvious  that  however  artistically  the 
operation  itself  may  be  conducted,  it  will  be  followed  by  serious  conse- 
quences. The  position  of  this  artery  must  be  taken  into  consideration  in 
the  performance  of  tracheotomy  below  the  thyroid  body.  The  surgeon 
must  be  prepared  to  meet  occasionally  with  an  arterial  trunk  from  the 
innominate*  running  obliquely  over  the  trachea  (as  Liicke  did  in  one  case). 
The  artery  is  the  thyroidea  ima. 

Ligature  of  the  first  part  of  the  subclavian  artery  and  its  dangers  have 
already  been  alluded  to.  It  must  be  remembered  that  even  in  its  normal 
relations  -(as  in  the  present  instance)  the  left  subclavian  artery  lies  in  a 
niche  of  pleura,  and  that  it  has  not  been  pushed  against  the  pleura  by 
means  of  the  enlarged  thyroid  gland.  (Plate  IX  in  the  large  atlas 
should  be  referred  to.)  It  can  be  readily  seen  from  the  plate  that 
swellings  of  the  thyroid  body  may  push  the  oesophagus  out  of  position, 
and  displace  the  trachea  backwards.  In  the  superior  aperture  of  the 
thorax  the  oesophagus  normally  inclines  to  the  left  side,  and  attains  its 
greatest  deviation  in  the  region  of  the  second  or  third  dorsal  vertebra.  I 
have  observed  exactly  the  same  condition  in  another  section  made  on  a 
normal  male  subject. 

*  In  a  case  in  which  I  performed  tracheotomy  on  a  man,  set.  50,  I  found  the  innominate  artery 
running  obliquely  across  the  trachea  below  the  isthmus. — TR. 


PLATE   IX  /  79 

Pirogoff  (tab.  i,  fasc.  ii),  in  a  transverse  section  made  between  the  first 
and  second  dorsal  vertebrae  in  a  powerful  man,  shows  the  oesophagus 
placed  at  the  side  of  the  trachea ;  and,  indeed,  unless  the  oesophagus 
be  much  dilated  (as  in  the  case  from  which  Plate  I  was  taken),  it 
does  not  project  towards  the  median  line.  This  fact  renders  it  evident 
that  in  the  operation  of  cesophagotomy,  if  there  be  no  tumour  of  the 
thyroid  body  of  the  left  side,  the  oesophagus  must  be  looked  for  on 
the  left  side  of  the  trachea ;  and  from  the  plate  it  is  clear  that  the 
operation  is  similar  to  that  of  finding  the  left  common  carotid  or  ver- 
tebral arteries.  The  close  relation  of  the  recurrent  laryngeal  nerve  is 
to  be  noticed. 

Under  the  pectoral  muscles,  on  the  outside  of  the  cavity  of  the  thorax, 
are  the  brachial  plexus  and  subclavian  vein,  and  between  them  is  the 
subclavian  artery.  If  the  pectoralis  major  be  removed  with  the  muscular 
branches  of  the  acromio-thoracic  artery,  a  thin  fascia  is  met  with  which 
passes  over  the  short  head  of  the  biceps,  the  coraco-brachialis  and  the 
pectoralis  minor.  It  extends  inwards  as  far  as  the  sterno-clavicular  articu- 
lation, and  envelopes  the  subclavius  muscle.  The  fascia  then  passes 
upwards  along  the  first  rib,  at  the  line  of  junction  with  the  sharp  edged 
coraco-clavicular  fascia,  and  terminates  in  a  sickle-shaped  margin.  An 
aperture  is  formed  externally  and  above,  resembling  the  saphenous  opening 
in  the  thigh,  which  permits  of  the  passage  of  the  cephalic  vein,  the 
acromial  axis,  and  the  external  anterior  thoracic  nerve.  Below  this  is 
Mohrenheim's  fascia  and  the  section  has  so  passed  that  the  continuity  of 
this  fascia  is  not  interrupted,  but  is  shown  by  means  of  a  white  line. 
The  fascia  forms  with  the  posterior  lamina  a  sheath  for  the  pectoralis 
major  and  coraco-brachialis,  and  constitutes  at  the  same  time  the  ante- 
rior layer  of  the  sheath  of  the  axillary  vessels.  Higher  up  it  attaches 
the  vein  to  the  subclavius  muscle  and  clavicle.  Wounds  of  the  vein 
at  this  spot  may  be  attended  by  a  dangerous  entry  of  air  into  the 
heart. 

The  posterior  layer  of  the  sheath  of  the  vessels  is  formed  by  the  fascia 
of  the  serratus  magnus  and  intercostal  muscles ;  the  external  layer  being 
derived  from  the  fascia  of  the  subscapularis  muscle.  The  cavity  of  the 


80 


PLATE   IX 


shoulder-joint  is  indicated  by  the  black  line  which  marks  out  the  capsule; 
the  folds  are  well  shown  which  facilitate  rotation  of  the  head  of  the 
humerus. 

The  strengthening  of  the  capsular  ligament  by  the  insertion  of  the 
tendons  of  the  subscapularis  and  teres  minor  are  well  seen;  and  on  the 
right  side  the  bursa,  which  lies  between  the  tendon  of  the  subscapularis 
and  the  capsular  ligament,  is  indicated. 


FlQ.    1. 


JB 


Subject  A.— Male,  aet.  22.     Normal.     Plate  X. 

1.  Trachea.     2.  (Esophagus.     3.  Left  innominate  vein.     4.  Bight  innominate  vein. 
5.  Innominate  artery.     6.  Left  common  carotid  artery.     7.  Left  subclavian  artery. 


In  order  to  show  by  plane  sections  the  changes  in  position  which  are 
brought  about  by  pathological  conditions  of  the  lungs  and  pleurae,  I  have 
arranged  two  of  Pirogoff's  plates  so  as  to  exhibit  surfaces  corresponding 
with  those  in  my  own  work,  that  is  to  say,  viewed  from  above  down- 
wards. They  are  reduced  to  half  scale,  and  fig.  1  represents  the  central 
portion  of  my  own  Plate  X. 

The  surrounding  muscles  and  upper  extremity  are  not  represented,  in 
order  to  make  the  woodcut  clearer. 

Fig.    2   represents   large  tubercular   cavities  in  the  upper  lobe  of  the 


PLATE   IX 


81 


left  lung,  and  is  taken  from  a  series  illustrating  dislocation  of  the  heart 
and  lungs. 

FIG.  2. 


Subject  B. — Male,  set.  18.     Tuberculosis,  Pirogoff,  ii,  2,  3. 

1.  Trachea.     2.  (Esophagus.     3.  Left  innominate  vein.     4.  Bight  innominate  vein. 
5.  Innominate  artery.     6.  Left  common  carotid  artery.     7.  Left  subclavian  artery. 

The  section  passes  pretty  much  at  the  same  level  as  in  my  own  plate, 
and  can  therefore  be  conveniently  compared  with  it.  Pirogoff  represents 
both  portions  of  the  section,  as  the  saw  had  removed  so  much  that  there 
was  considerable  difference  in  the  two  sides.  Pirogoff  in  his  text,  fasc.  ii, 
p.  10,  states  that  after  freezing  the  body  the  upper  extremities  were 
removed  with  the  scapulae.  The  pulmonary  and  costal  pleurae  were  closely 
adherent.  The  cavities,  which  are  shown  by  the  deeper  shading,  have 
attained  an  enormous  size,  and  the  left  side  of  the  thorax  was  consider- 
ably more  sunken  in  than  the  right ;  on  the  woodcut,  however,  it  does 
not  appear  very  remarkable.  Between  the  first  and  second  ribs  only  is 
a  slight  incurvation  of  the  contour  of  the  chest  to  be  noticed.  But 
the  transverse  diameter  of  the  left  portion  of  the  thoracic  cavity  is 
considerably  larger  than  the  right.  It  is  unfortunately  not  stated  by 
Pirogoff  whether  any  encysted  pleuritic  effusion  existed  lower  down,  which 
might  have  been  the  cause  of  this  increase  in  breadth;  consequently 

11 


82 


PLATE   IX 


there  is  little  of  importance  to  remarl^  as  to  the  cause  of  this  altered  form 
of  the  mediastinal  space.     Fig.  3  shows  a  section  which  corresponds  with 


FIG.  3. 


Subject  C. — Adult  male.    Left  lateral  pneumothorax.     Pirogoff,  ii,  2,  3,  \. 

1.  Trachea,    2.  (Esophagus.     3.  Left  innominate  vein.    4.  Right  innominate  vein. 
5.  Innominate  artery.     6.  Left  common  carotid  artery.     7.  Left  subclavian  artery. 

mine,  but  the  section  has  passed  nearly  a  vertebra  deeper.  It  is  from  the 
body  of  an  adult  male  who,  shortly  before  death,  had  pneumothorax  of  the 
left  side. 

The  apex  of  the  left  lung  was  so  compressed  by  the  mixture  of  pus  and 
air  that  it  is  not  visible  in  this  section ;  on  the  right  side  the  lung  was 
divided  near  its  cupola.  It  is  evident  that  the  distension  of  the  left  side 
of  the  thorax  is  not  due  to  the  elevation  of  the  ribs  only,  but  also  to  the 
dragging  inwards  of  the  mediastinum ;  and  in  consequence  of  this  the 
structures  in  the  upper  portion  of  this  thoracic  cavity  appear  to  be  pushed 
considerably  out  of  their  places. 


\> 


PLATE    X 

THE  upper  surface  of  the  section  is  here  shown ;  it  is  from  the  same 
body  as  the  foregoing,  and  is  about  1*4  inch  thick,  the  saw  through  the 
inferior  surface  of  the  arch  of  the  aorta,  about  one  fifth  of  an  inch  below 
the  division  of  the  trachea,  dividing  the  fourth  dorsal  vertebra  just  below 
its  middle,  and  the  sternum  immediately  below  its  articulation  with  the 
first  rib,  so  that  on  the  right  side  a  small  portion  only  of  its  cartilage 
is  shown.  The  scapula  is  divided  below  its  spine,  and  the  humerus  below 
the  tuberosities.  The  section  has  passed  just  through  the  upper  edge 
of  the  teres  major,  laying  free  the  course  of  the  posterior  circumflex 
artery  and  a  portion  of  the  circumflex  nerve.  The  nerve  and  artery  pass 
directly  into  the  deltoid  muscle.  The  section  shows  clearly  that  both  these 
structures  must  pass  behind  the  humerus  in  order  to  attain  the  middle 
of  the  deltoid. 

The  axillary  vessels  and  nerves  lie  on  the  subscapularis  and  under  the 
coraco-brachialis.  Their  position  with  regard  to  each  other  is  altered  from 
the  preceding  section,  the  artery  lying  more  between  the  nerve  and  vein, 
but  so  enclosed  in  the  heads  of  the  median  nerve  that  it  appears  pushed 
from  the  vein  by  the  great  nervous  mass. 

The  thorax  is  divided  close  to  the  lower  border  of  the  first  rib,  and  on  the 
right  side  of  the  sternum  is  a  small  portion  of  a  costal  cartilage,  whose 
position  corresponds  with  a  broader  section  of  the  manubrium  sterni  than 
the  preceding.  Behind  the  sternum  are  the  origins  of  the  sterno.-hyoid  and 
sterno- thyroid ;  laterally  are  the  intercostal  muscles,  which  are  attached  to 
the  second,  third,  and  fourth  ribs,  and  which  help  to  close  in  the  chest  wall. 
The  section  of  the  fourth  dorsal  vertebra  is  seen  at  the  back  of  the  cavity, 
and  is  divided  so  close  to  its  lower  surface  that  the  articular  processes  of 
the  fifth  dorsal  vertebra  come  into  the  section ;  on  the  right  side  a  small 


84  PLATE   X 

portion    of   the  fifth   rib   is   seen,  and  on  the  left  side  the  boundary  is 
formed  by  the  intra-thoracic  fascia. 

The  form  of  the  section  of  the  thorax  is  that  of  a  heart  as  seen  on  a 
playing  card,  and  is  produced  by  the  projection  of  the  body  of  the  vertebra 
and  the  recession  of  the  hinder  end  of  the  ribs.  It  has  been  remarked  by 
Hyrtl  ('  Topog.  Anat.,'  1860,  i,  492)  that  this  form  is  associated  with  the 
upright  position  of  man,  since  by  this  formation  the  centre  of  gravity  of 
the  thoracic  viscera  is  advanced  nearer  to  the  support  of  the  trunk.  This 
advantage  is  not  possessed  by  other  animals,  and  one  cannot  maintain 
that  this  form  is  only  a  consequence  of  this  upright  condition,  since,  in  the 
newly  born  infant,  the  curvature  of  the  spine  amounts  almost  to  nothing 
(Pirogoff,  a  a  0,  fasc.  i  A,  tab.  xvi,  fig.  3).  But  this  heart-shaped  form  of 
the  section  of  the  thorax  exists  in  new-born  children,  as  I  can  state 
from  my  own  observations.  Pirogoff's  transverse  sections  also  show  it 
(fasc.  ii,  tab.  xx).  I  find,  however,  that  the  relation  of  the  breadth 
to  the  depth  in  children  is  considerably  more  variable  than  is  that  of 
the  adult  at  a  corresponding  level.  In  the  newly  born  child  the 
antero-posterior  diameter  is  to  the  transverse  diameter  nearly  in  the 
proportion  of  1  to  2,  whereas  in  the  present  plate  of  an  adult  it  is 
as  1  to  3  ;  in  the  old  man,  on  the  other  hand,  the  proportion  is  more 
like  the  child's,  viz.  1  to  2*5.  The  lungs  are  in  the  condition  of  expira- 
tion, and  that  to  such  an  extent  that  during  life  the  respiration  pause 
was  never  reached.  As  the  contraction  of  the  lungs  after  death  is 
dependent  on  their  elasticity,  the  size  which  they  gradually  assume 
must  be  so  much  the  smaller  the  younger,  sounder,  and  more  elastic 
the  said  lungs  are.  And  as  the  contraction  of  the  lungs  depends  pro- 
portionately on  the  position  of  the  diaphragm,  with  the  heart,  liver, 
and  spleen,  there  is  naturally  in  young  powerful  individuals  a  higher 
position  of  the  diaphragm  and  of  its  neighbouring  organs  after  death 
than  in  the  aged  or  diseased.  If  the  section  of  the  old  man  be  com- 
pared with  the  present  plate,  it  will  be  seen  that  it  is  deeper  by  a 
vertebra  (the  sixth  in  the  old  man).  Consequently,  in  the  definition  of  the 
position  of  the  arch  of  the  aorta,  division  of  the  bronchi,  &c.,  the  age  of 
the  individual  must  be  always  taken  into  consideration,  and  no  fixed 


PLATE   X  85 

level  of  a  vertebra  for  the  individual  thoracic  viscera  can  be  given.  The 
lungs  themselves  are  divided  through  the  lower  portion  of  their  upper 
lobes,  so  that  on  the  left  side  a  small  portion  of  the  under  lobe  falls  into 
the  section,  which,  as  the  plate  shows,  quickly  increases  in  size  down- 
wards. Between  the  lungs,  in  front,  is  the  thymus  gland,  which  is 
sometimes  found  as  late  as  the  twentieth  year,  and  consequently  renders 
a  mesial  section  possible  on  the  young  person,  without  opening  the  pleural 
cavity.  In  older  subjects,  after  the  atrophy  of  the  thymus  gland,  both  lungs 
lie  so  close  to  each  other  that  in  such  a  section  it  is  impossible  to  avoid 
opening  the  pleural  cavity. 

I  omitted  to  speak  of  the  details  of  the  form  of  the  mediastinum ;  repre- 
sentations of  it  are  given  by  Hyrtl,  '  Top.  Anat.,'  i,  547,  and  by  Luschka  in 
Virchow's  '  Archiv,'  xv,  369. 

There  is  nothing  more  variable  in  shape  than  the  mediastinal  space, 
for  ib  is  confined  by  fixed  limits  only  in  front  and  behind,  on  both  sides  the 
boundaries  are  moveable. 

The  alteration  in  capacity  of  the  lung  during  breathing  must  also 
alter  the  position  of  the  mediastinum.  It  further  obtains  that  the 
contents  of  this  mediastinal  space  are  moveable  and  changeable.  The 
oesophagus  when  distended  takes  up  more  space  than  when  empty  and 
collapsed.  The  same  remark  applies  to  the  great  vessels,  which  alter 
in  size  considerably  after  each  contraction  of  the  heart.  The  medi- 
astinum in  the  region  of  the  sterno-clavicular  articulation,  as  shown 
in  the  plate,  passes  downwards  and  inwards,  so  that  the  space  beneath 
it  is  contracted  and  funnel-shaped.  In  consequence  of  the  position  of 
the  thymus  gland  it  is  possible  to  reach  the  upper  edge  of  the  arch  of  the 
aorta  with  its  three  branches,  and  the  superior  caval  and  innominate  veins, 
without  necessarily  opening  the  pleura,  and  perforation  of  that  portion  of 
the  trachea  which  lies  behind  the  manubrium  sterni  may  take  place  from 
the  anterior  wall  of  the  chest  without  the  pleura  being  involved.  In  order 
to  compare  the  relations  produced  by  pathological  changes  at  similar 
levels,  I  have  taken  some  reduced  and  reversed  figures  from  Pirogoff, 
so  that  they  may  correspond,  as  far  as  the  observer  is  concerned,  with  my 
own  plates. 


86 


PLATE   X 


Fig.  1  is  reduced  from  Plate  XI  of  this  Atlas. 

Pirogoff's  drawing,  Fig.  2,  which  shows  a  body  affected  with  left  pneu- 
mothorax,   was   reversed  and   reduced   so    that   it   might    be    the   more 


FIG.  1. 


R 


Subject  A.— Thorax.     Male,  set.  22.     Normal.     Plate  XI,  J. 
1.  Trachea.     2.  (Esophagus.     3.  Superior  vena  cava.    4.  Arch  of  aorta. 


readily  compared  with  mine.  The  section,  according  to  Pirogoff's  descrip- 
tion, passed  through  the  second  intercostal  space,  and  divided  the  third, 
fourth,  and  fifth  ribs  to  the  lower  border  of  the  second  dorsal  vertebra, 
so  that  in  subject  C  the  sternum  must  have  been  placed  considerably 
higher  than  in  my  preparation.  Whilst  the  posterior  osseous  portion 
shows  relations  similar  to  mine,  the  sections  through  the  sternum  differ 
by  a  rib  and  an  intercostal  space.  This  elevated  position  of  the  sternum 
can  be  readily  explained  from  the  pneumothorax,  and  the  emphysema 
existing  on  the  right  side. 

The  left  lung  lies  compressed  upon  the  vertebrae  by  means  of  a  pseudo- 
membranous  cord  which  is  attached  to  the  wall  of  the  chest;  the  right 
lung  which  is  immensely  distended  by  secondary  emphysema,  shows  no 
folds  in  the  pleura,  such  as  are  to  be  seen  in  my  plates.  The  superior  vena 
cava  is  compressed. 


PLATE   X 


87 


This  thorax  has  an  entirely  different  shape  from  fig.  1,  being  fully  dis- 
tended.    On  account  of  the  greater  pressure  in  the  left  half  of  the  thorax, 


FIG.  2. 


Subject  C. — Adult  thorax.     Left  lateral  pneumothorax.     Pirogoff,  ii,  b.  2,  ^. 
1.  Trachea.       2.  (Esophagus.      3.  Superior  cava.      4.  Aorta.      5.  Azygos  vein. 

the  structures  lying  in  the  mediastinum,  the  trachea,  oesophagus,  and  aorta, 
are  pushed  over  towards  the  right  side.  Pirogoff  has  figured  more  sections 
from  each  body,  so  that  I  was  induced  especially  to  indicate  the  individual 
subject  with  capitals,  in  order  that  the  reader  may  be  able  to  find  the  same 
body  on  the  different  sections. 

Subject  A  is  the  powerful  man  from  which  nay  principal  plates  are 
taken.  Subjects  B,  0,  D,  &c.,  are  from  Pirogoff.  Subject  0,  accord- 
ing to  his  statement,  is  from  a  man  of  middle  age  who  died  in  the 
hospital  and  had  considerable  pleuritic  effusion.  I  have  found,  moreover, 
a  case  of  hydropericarditis  with  insufficiency  of  the  semilunar  valves  of 
the  aorta. 

The  section  in  fig.  3,  which  likewise  is  a  reverse  of  a  plate  in  Pirogoff's 
atlas,  shows  the  same  relations  of  the  skeleton  as  mine.  The  right  lung, 
which  was  comparatively  but  little  affected,  corresponds  almost  exactly 


88 


PLATE   X 


with  mine.  The  anterior  portion  of  the  apex  of  the  lung  is  slightly 
drawn  over  to  the  left  side  in  consequence  of  the  adhesion  of  the  pleurae 
to  the  remains  of  the  thymus  gland.  The  left  lung  shows  important 
changes,  due  to  infiltration  and  the  formation  of  cavities.  On  account  of 


Fia.  3. 


Subject  D.  —  Thorax.     Male,  set.  20.     Tuberculosis.     Plem-isy.     Pirogoff,  ii,  5,  i, 
1.  Tracbea.     2.  CEsopbagus.     3.  Superior  cava.     4.  Arcb  of  aorta. 


the  pleuritic  effusion  the  left  side  of  the  thorax  does  not  appear  much 
sunken  in.  According  to  Pirogoff  (p.  15,  fasc.  ii),  the  cellular  tissue  in 
the  mediastinum  was  essentially  altered  by  the  previous  inflammation. 
It  shows  strong  attachments  of  the  pleura  to  the  surface  of  the  ribs  and  to 
the  inside  of  the  mediastinal  space,  as  well  as  adhesions  of  organs  lying 
near  to  each  other  —  a  condition  which  cannot  be  intelligibly  represented 
in  the  plate.  The  patient  was  a  young  man,  set.  20,  who  died  in  the 
hospital. 

The  woodcut  fig.  4  is  also  from  Pirogoff,  and  was  taken  from  the  body 
of  a  man  who  died  of  "  scorbutic  pleuritis,"  with  great  effusion  of  blood 
and  pus  in  the  pleural  cavities.  The  anterior  surface  of  the  left  lung  was 


PLATE   X 


89 


so  adherent  to  the  thickened  pleura,  that  the  pleural  cavity  was  divided 
into  two  portions,  each  holding  a  considerable  quantity  of  blood  and  pus. 


Fig.  4. 


Subject  E. — Male  thorax.     Lateral  empyema  of  left  side.    Accumulation  of  serum  in  right 
pleural  cavity.     Pirogoff,  ii,  18,  1,  ^. 

1.  Trachea.     2.  (Esophagus.     3.  Superior  cava.     4.  Arch  of  aorta. 

The  left  lung  was  adherent  to  the  wall  of  the  chest,  and  in  consequence 
of  the  pressure  from  the  pleuritic  effusion  the  pericardium  had  become 
irregular  in  shape.  The  left  side  of  the  heart  was  much  hypertrophied,  and 
the  mitral  valve  was  covered  with  vegetations.  The  section  which  was 
made  at  the  same  level  as  mine,  namely,  through  the  middle  of  the  first 
intercostal  space,  passed  through  the  second,  third  and  fourth  ribs  and 
divided  the  fourth  dorsal  vertebra  in  its  lower  half ;  great  deviation  of  the 
mediastinum  is  shown.  On  account  of  the  collection  of  fluid  in  the  left 
pleural  cavity  the  trachea  is  pushed  over  towards  the  right  side,  and  the 
oesophagus  lies  the  breadth  of  half  a  vertebra  from  its  usual  position 
towards  the  right  side,  so  that  deglutition  must  have  been  considerably 
interfered  with.  The  plate  also  shows  a  dislocation  of  the  superior  vena 
cava  almost  to  the  middle  of  the  right  half  of  the  thorax.  In  consequence 

12 


90  PLATE   X 

of  the  previous  inflammation  in  the  mediastinum  a  considerable  amount  of 
adhesion  of  the  structures  contained  in  it  has  been  produced,  whilst  the 
arch  of  the  aorta  has  been  so  dislocated,  and  its  lumen  so  altered,  that  it 
appears  as  a  narrow  cleft.  Such  changes  must  have  exerted  their  influence 
upon  the  heart ;  unfortunately  they  are  not  explained  in  Pirogoff's  text. 
The  change  in  position  of  the  right  lung  was  probably  brought  about  by  the 
organisation  of  the  pleuritic  effusion,  especially  noticeable  in  the  sinking-in 
of  the  left  half  of  the  thorax,  as  seen  at  about  the  section  of  the  second 
rib. 


X 


~ 

H 


PLATE    XI 

THIS  plate  represents  the  upper  surface  of  a  lamina  about  an  inch  and 
a  half  thick,  which  was  cut  by  a  section  passing  through  the  trunk  imme- 
diately beneath  the  sternal  end  of  the  second  rib  and  the  upper  border 
of  the  sixth  dorsal  vertebra  ;  the  saw  passed  out  through  the  fat  of  the 
axilla,  dividing  the  humerus  at  the  insertion  of  the  teres  major. 

Attached  to  the  bone  are  the  tendinous  insertions  of  the  great  pectoral 
muscles,  and  on  account  of  the  position  of  the  arms  as  regards  the  trunk 
they  are  so  disposed  as  to  exhibit  a  flat  upward  curve,  and  have  been 
twice  cut.  Under  the  tendon  of  the  pectoralis  major  lie  the  biceps  and 
coraco-brachialis,  and  close  under  the  last-named  muscle  are  the  vessels 
and  nerves.  The  axillary  artery  is  surrounded  by  the  plexus,  and  is  found 
next  the  muscle.  The  fascia  of  the  coraco-brachialis  must  be  divided  to 
ligature  this  artery  (after  the  arm  has  been  raised),  and  the  vessel  should 
be  reached  from  the  sheath  of  the  muscle,  which  can  be  easily  drawn 
outwards;  thus  there  will  be  little  risk  of  pinching  up  and  wounding  the 
nerves  and  veins.  Those  portions  of  the  trunk  which  are  divided  in  the 
second  intercostal  space  are  of  very  great  importance.  The  section  of 
the  great  vessels  passes  immediately  over  their  valves,  and  the  left 
auricle  with  the  upper  wall  of  the  auricular  appendix  are  shown.  The  left 
auricular  appendix  lies  more  deeply,  and  is  seen  in  front  of  the  .ascending 
aorta. 

Immediately  behind  the  sternum  the  lungs  and  pleura3  approximate 
each  other  so  closely,  that  only  a  very  small  interspace  remains.  This 
narrow  space  leads  from  the  anterior  mediastinum  to  the  region  of  the 
thymus  gland;  a  sagittal  section  in  the  mesial  plane  in  this  body  must 
have  opened  the  right  pleural  cavity. 


92  PLATE    XI 

The  contour  of  the  pericardium  is  clearly  shown;  it  extends  at  this 
level  considerably  further  back  on  the  left  side  than  on  the  right,  corre- 
sponding with  the  higher  position  of  the  left  auricular  appendix.  On  the 
right  side  it  has  been  opened  in  front  of  the  superior  vena  cava,  and  extends 
between  it  and  the  aorta  posteriorly  to  the  right  branch  of  the  pulmonary 
artery,  playing  the  part  of  a  bursa  by  permitting  the  necessary  movement 
of  these  vessels  upon  each  other.  As  the  trunks  of  the  vessels  which 
pass  from  the  lung  into  the  left  auricle,  and  from  the  right  ventricle  to  the 
lung,  run  horizontally,  a  section  which  passes  through  the  roots  of  the 
lungs  exposes  much  more  of  their  length,  whilst  the  vessels  of  the 
greater  circulation,  which  pass  more  vertically  to  and  from  the  heart, 
appear  divided  more  transversely.  The  pulmonary  artery  is  the  most 
important  to  examine  of  the  vessels  of  the  lesser  circulation,  as  it  is 
exposed  for  a  large  portion  of  its  course.  It  is  met  with  close  to  its 
origin,  and  its  right  branch  is  divided  throughout  its  course.  The  left 
branch  does  not  lie  in  the  same  plane,  but  it  is  also  divided.  It  rises  up 
somewhat  in  its  course  to  the  left  lung,  arching  over  the  left  bronchus 
and  left  auricle.  The  trunk  of  the  pulmonary  artery  runs  somewhat  to 
the  left,  backwards  and  upwards,  and  can  be  seen  in  the  upper  surface  of 
the  section. 

It  is  evident  that  the  aorta  and  pulmonary  artery  are  fixed  together, 
whilst  the  former  is  capable  of  movement  upon  the  vena  cava.  The 
relation  of  the  aorta  to  the  right  pulmonary  artery  is  important,  as  in 
aneurismal  dilatations  of  the  first  part  of  the  aorta  compression  of  the 
right  pulmonary  artery  may  be  expected.  The  position  of  the  valves  of 
the  pulmonary  artery  and  aorta  with  regard  to  the  chest  wall  were  accurately 
defined  in  the  preparation,  and  can  be  deduced  approximately  from  the 
plate.  The  pulmonary  orifice  lay  behind  the  left  border  of  the  sternum 
under  the  upper  margin  of  the  third  costal  cartilage.  The  aortic  orifice 
lay  behind  the  left  half  of  the  sternum  on  a  level  with  the  third  costal 
cartilage,  behind  and  to  the  right  of  the  pulmonary  opening.  The  cur- 
vature of  the  aorta  behind  the  first  part  of  the  pulmonary  artery,  with 
the  position  of  its  valves,  is  rendered  as  accurately  as  possible.  It  must 
however  be  expressly  understood  that  such  definitions  cannot  represent 


93 

with  absolute  accuracy  the  relations  on  the  living  body.  Apart  from  the 
influence  which  maintains  the  filling  of  the  vessels,  the  position  of  the 
heart  and  its  great  branches  is  determined  chiefly  by  the  lungs  and 
diaphragm,  and  it  varies  with  each  change  of  position  of  these  important 
connexions.  (This  will  be  referred  to  again  in  the  text  accompanying 
the  next  plate.)  Both  bronchi  are  clearly  seen ;  the  left  is  divided  more 
obliquely,  in  consequence  of  its  being  less  vertical  than  the  right, 
and  as  its  ramifications  lie  in  the  plane  of  section,  more  of  its  branches 
are  seen;  whilst  as  the  right  has  been  divided  more  transversely,  most 
of  its  branches  have  been  separated.  Between  them,  at  the  root  of  the 
lung,  are  a  number  of  the  characteristic  pigmented  bronchial  glands. 

Nearly  in  the  centre,  in  front  of  the  sixth  dorsal  vertebra,  is  the 
oesophagus,  and  behind  it,  to  the  left  side,  is  the  descending  aorta,  which 
already  begins  to  take  a  direction  towards  the  middle  line.  Between  the 
oesophagus  and  the  aorta  is  the  thoracic  duct,  which  in  this  instance  is 
double.  The  vagus  lies  on  the  right  side  near  the  oesophagus  and  the 
vena  azygos  major;  on  the  left  side  it  lies  between  the  bronchus  and 
descending  aorta. 

The  practical  physician  will  notice  with  interest  the  changes  which 
pathological  conditions  have  given  rise  to  in  these  sections.  I  have,  there- 
fore, introduced  two  plates  from  Pirogoff,  which  have  been  taken  from  the 
bodies  of  patients.  Fig.  1,  taken  at  the  same  level  as  my  plate,  shows 
extensive  pericardial  exudation. 

The  immense  expansion  which  the  pericardium  has  attained  at  the 
roots  of  the  great  blood-vessels  is  remarkable ;  both  pleural  sacs  are 
widely  drawn  asunder,  and  the  right  especially  has  acquired  a  consider- 
able inflexion.  The  pulmonary  artery  with  its  right  branch  has  slightly 
changed  its  position  with  regard  to  the  middle  line ;  the  aorta  lies  con- 
siderably further  towards  the  right  side  than  is  normal,  and  is  pushed  far 
away  from  the  vena  cava.  On  account  of  the  exudation  all  the  vessels  seem 
to  be  pushed  towards  the  vertebral  column. 

The  section  corresponds  with  that  given  by  Pirogoff  (fasc.  ii,  p.  22), 
and  passes  through  the  second  intercostal  space,  dividing  the  third,  fourth, 
and  fifth  ribs  of  both  sides  and  the  fourth  costal  cartilage  at  the  level 


94 


PLATE    XI 


of  its  upper  margin.  The  age  of  the  man,  who  had  lain  in  hospital  a 
long  time,  is  not  clearly  denned,  and  is  as  of  middle  life.  In  any 
case  the  age  was  greater  than  that  of  my  subject.  It  is  remark- 
able that,  although  in  the  region  of  the  sternum  both  sections  began 
almost  exactly  at  the  same  level,  they  struck  different  vertebrae;  in 
PirogofTs  case  the  fourth,  in  mine  the  sixth.  As  the  definition  of  the 
position  of  the  heart  with  regard  to  the  bones  of  the  anterior  wall  of  the 


FIG.  1. 


Adult  male  thorax.     Hydro-pericarditis.     Insufficiency  of  aortic  valves.     Pleurisy. 

Pirogoff,  ii,  p.  1,  £. 

1.  Bronchi.     2.  (Esophagus.     3.  Pulmonary  artery.    4.  Ascending  aorta. 
5.  Superior  vena  cava.     6.  Descending  aorta. 


chest  is  of  clinical  importance,  I  have,  in  spite  of  the  difference  of  the 
vertebrae  of  Pirogoff's  plate,  chosen  it  for  the  sake  of  the  comparison,  as 
the  section  happens  to  pass  through  the  same  intercostal  space  as  mine. 

It  must  be  borne  in  mind  that  owing  to  the  exudation  into  the  peri- 
cardial  and  pleural  cavities  in  Pirogoff 's  subject,  the  ribs  are  raised  and 
their  anterior  extremities  lie  two  vertebras  higher  than  in  my  case. 

The  following  woodcut,  Fig.  2,  shows  the  variation  in  the  position  of 
the  parts  of  a  similar  section  in  pleuritic  effusion  of  the  left  side  with 
pneumo-thorax.  The  subject  is  the  same  as  in  Fig.  2  of  the  text  of 


PLATE    XI 


95 


Plate   X.     The  expansion  of  the  left  side  of  the  thorax,  and  the  lateral 
displacement  of  the  great  vessels,  can  be  clearly  made  out. 

The    commencement  of  the  pulmonary   artery   lies   behind   the   right 


FIG.  2. 


m 


Subject  C. — Adult  male  thorax.     Left  lateral  pneumo- thorax.     Pirogoff,  ii,  7,  3,  5. 

1.  Bronchi.     2.  (Esophagus.     3.  Pulmonary  artery.    4.  Ascending  aorta. 
5.  Superior  vena  cava.     6.  Descending  aorta. 


border   of  the  sternum,  and   that  of  the  aorta   behind   the  third  costal 
cartilage. 

Pirogoff 's  section  (cf .  text  to  plate,  '  Atlas,'  fasc.  ii,  p.  28)  runs 
horizontally  through  the  upper  border  of  the  third-  costal  cartilage, 
dividing  the  third,  fourth,  and  fifth  ribs  of  both  sides ;  it  passes  also 
through  the  upper  border  of  the  fifth  dorsal  vertebra.  Here  the 
section  passes  a  vertebra  higher  than  in  my  case;  this  resulted  from 
the  expansion  of  the  thorax,  and  the  position  of  the  ribs  consequent 
on  inspiration.  It  is  remarkable  that  both  right  and  left  sides  of  the 
thorax  are  equally  raised,  so  that  they  show  a  closely  symmetrical 
division  of  the  ribs.  Besides  the  local  pleuritic  adhesion,  which  stretches 


96 


PLATE    XI 


like  a  cord  from  the  inner  surface  of  the  ribs  to  the  lung,  there  are  other 
and  wider  bands  which  divide  the  pleural  cavity  into  three  portions.  The 
left  lung  is,  moreover,  very  much  compressed  and  adherent  to  the  costal 
pleura,  so  that  its  section  appears  polygonal. 

As  the  normal  relations  of  the  thoracic  organs  have  been  exhaustively 
treated  of  by  Luschka,  Henle,  Meyer,  and  others,  I  must  refer  the  reader 
to  their  works,  and  proceed  with  a  description  of  certain  results  of 
observations  on  dislocation  of  the  heart  from  collections  of  fluid  in  the 
pleural  cavities. 

Fig.  3  shows  the  normal  relations  of  the  heart  to  the  anterior  wall 
of  the  chest,  as  determined  from  numerous  examinations  which  I  have 


FIG.  3. 


FIG.  4. 


Normal  position  of  the  heart,  £. 


Dislocation  of  the  heart.    Pleuritic  exudation 
on  the  left  side,  £. 


made  on  young  male  subjects.  After  injecting  the  heart,  and  using  only 
moderate  pressure,  the  left  auricular  appendix  became  more  visible  than 
is  usually  the  case  when  it  is  empty. 

Fig.  4  represents  a  very  considerable  dislocation  of  the  heart  to  the 
right  side,  produced  by  pleuritic  effusion.  The  body  lying  on  the 
back,  the  heart  was  fixed  to  the  anterior  and  posterior  walls  of  the  thorax 
by  six  long  needles,  and  the  position  of  each  portion  accurately  defined 


PLATE   XI 


97 


with  regard  to  the  anterior  wall  of  the  chest.  It  will  be  observed  that  the 
dislocation  of  the  heart  is  considerably  greater  as  regards  its  apex  than  its 
base,  and  that  at  the  same  time  a  rotation  towards  the  right  side  on  the 
long  axis  has  taken  place,  so  that  a  greater  projection  of  the  left  ventricle 
has  resulted.  The  vertical  position  of  the  heart's  axis  in  this  instance  was 
determined  by  exact  measurement. 

The  following  woodcuts  (5  and  6)  also  show  dislocation  of  the  heart 
from  effusion  into  the  pleural  cavities.  They  are,  however,  the  results  of 
experiments  which  were  made  by  myself  on  fresh  normal  bodies. 


FIG.  5. 


FIG.  6. 


Left  lateral  hydrothorax,  artificial,  ^th. 


Right  lateral  hydrothorax,  artificial,  ^th. 


The  bodies  were  placed  in  the  upright  position  and  care  was  taken  that 
the  tracheae  remained  open,  and  that  the  other  parts  were  in  their  normal 
positions,  and  disregarding  any  experiment  which  did  not  seem  to  be  com- 
plete, the  conditions  shown  in  the  accompanying  woodcuts  were  obtained. 

After  finishing  the  experiments  by  injecting  a  weak  solution  of  common 
salt,  the  trachea  was  closed,  so  that  on  opening  the  thorax  any  farther 
falling  together  of  the  lungs  should  be  impossible.  The  heart  was  fixed 
to  the  anterior  and  posterior  walls  of  the  thorax,  with  long  needles,  and  the 
intercostal  spaces  subsequently  opened,  in  order  to  determine  the  position 
of  the  heart  with  regard  to  the  framework  of  the  chest.  It  was  found  that 

13 


98  PLATE   XI 

the  apex  of  the  heart  was  pushed  considerably  backwards ;  and  so  also  was 
the  base,  although  strengthened  by  the  great  vessels  forming  the  root 
of  the  lung.  There  was  lateral  rotation  of  the  heart  on  its  long  axis. 
The  quantity  of  fluid  injected  in  fig.  5  was  five,  and  in  fig.  6  six  pounds.  It 
was  observed  that  after  the  introduction  of  a  pound  and  a  half  of  fluid, 
there  was  an  evident  increase  of  dulness  on  percussion  in  the  region  of  the 
liver  (corresponding  with  the  observations  of  Seitz  and  Zamminer). 

As  bearing  on  these  experiments,  I  examined  Pirogoff's  plates  relating 
to  the  sections  of  a  subject  with  empyema  of  the  right  side  and  dislocation 
of  the  heart.  (The  section  had  been  made  after  freezing.)  I  also  col- 
lected material  from  the  same  author,  of  a  body  with  pneumo-thorax  of  the 
left  side. 

After  careful  measurements  on  the  different  plates,  the  contours  of  the 
dislocated  heart  were  constructed  and  shown  in  figs.  5  and  6  by  the  dotted 
lines,  so  that  a  comparison  with  the  results  of  my  own  researches  might  be 
instituted. 

In  PirogofFs  definitions  of  the  heart's  position,  exact  as  they  are,  the 
quantity  of  the  morbid  fluid  could  not  have  been  measured,  and  one 
cannot  expect  that  a  dislocation  of  the  heart  could  be  expressed  by  a 
surface  of  the  contours.  Moreover,  an  artificial  effusion  into  the  pleural 
cavity  could  never  produce  the  same  relations  as  a  gradually  increasing 
exudation.  But  it  follows  certainly  from  these  instances,  and  it  is  even 
proved  by  the  difference  of  methods,  that  in  dislocations  such  as  these,  the 
base  of  the  heart  does  not  remain  fixed,  but  that  it  is  considerably  moved 
from  its  place  (and  the  apex  likewise),  and  that  there  is  a  rotation  of  the 
heart  on  its  long  axis. 


PLATE    XII 

THIS  section,  like  the  one  just  described,  is  viewed  from  above  down- 
wards, the  thickness  of  the  lamina  being  about  one  inch  and  a  half.  The 
section  passed  through  both  nipples  and  the  third  intercostal  spaces, 
dividing  the  auricles  of  the  heart  and  their  valves.  It  passes  back- 
wards to  the  upper  border  of  the  eighth  dorsal  vertebra,  and  shows 
the  eighth  ribs  of  both  sides;  it  cuts  also  the  inferior  angle  of  the 
shoulder-blade. 

The  great  value  of  the  plate  consists  in  the  fortunate  section  through 
the  heart,  both  auricle  and  ventricle  being  opened.  The  left  auriculo- 
ventricular  opening  is  divided  nearly  in  half,  and  the  right  is  so  cut  at  its 
upper  border  that  a  view  is  obtained  of  the  ventricle.  At  first  sight  the 
cut  surface  of  the  heart  and  the  space  which  this  organ  occupies  seem 
immensely  large,  and  yet  a  subsequent  examination  shows  their  rela- 
tions to  be  normal.  From  the  oblique  position  of  the  heart  in  the 
thorax  a  transverse  section  of  the  body  would  not  divide  it  transversely 
but  obliquely;  therefore  its  walls  appear  much  thicker  than  they  really 
are. 

The  left  auricle  is  divided  not  far  from  its  base.  The  portion  of  it 
here  represented  shows  a  cavity  about  '3  of  an  inch  in  its  deepest  part, 
while  towards  the  right  side  the  section  rises  to  the  level  of  the  pulmonary 
veins.  A  small  portion  of  the  aortic  segment  of  the  mitral  valve  has  been 
taken  away ;  it  will  be  found  on  the  right  side  of  the  mitral  opening. 

Behind  the  left  auricle  the  great  cardiac  vein  is  seen  passing  to  the 
right  auricle  to  open  by  the  coronary  sinus  below  the  remains  of  the 
Eustachian  valve.  The  point  of  opening  lies  too  deeply  to  be  clearly  shown 
in  the  plate. 


100  PLATE   XII 

As  the  left  ventricle  lies  more  posteriorly  and  the  right  extends  more 
anteriorly,  the  auricular  septum  is  drawn  out  backwards  and  to  the  right 
side ;  the  left  auricle  lies  considerably  higher  than  the  right. 

The  inferior  vena  cava  projects  upwards  into  the  posterior  half  of  the 
right  auricle,  and  in  front  of  it  are  the  remains  of  the  Eustachian  valve. 
Still  more  anteriorly  the  auricle  bulges  outwards  and  downwards  to  a  depth 
of  about  an  inch  and  a  quarter,  rising  again  to  open  into  the  right  ventricle 
and  by  means  of  the  auriculo -ventricular  opening,  which  is  guarded  by 
the  tricuspid  valve.  In  front  of  the  tricuspid  valve  is  the  right  ventricle, 
which  is  opened  by  the  section,  and  from  which  the  section  has  carried 
away  the  root  of  the  pulmonary  artery.  From  the  anterior  wall  of  the 
ventricle  (the  section  of  which  is  seen  in  front)  one  of  the  musculi  papil- 
lares  passes  backwards  to  the  anterior  flap  of  the  valve,  and  behind  this, 
deeper  in  the  cavity  of  the  ventricle,  are  the  columns  carnese  of  the  hinder 
wall.  By  comparison  with  the  under  surface  of  the  next  section  the  position 
of  both  auricles  can  be  accurately  determined.  It  appears  that  the  cavity 
of  the  right  auricle  attains  the  level  of  the  lower  border  of  the  fourth,  to 
the  middle  of  the  third,  costal  cartilage,  and  that  its  corresponding  auricular 
appendix  reaches  to  the  upper  border  of  the  third  costal  cartilage.  Its 
greatest  breadth  extends  from  the  middle  of  the  left  half  of  the  sternum 
to  about  an  inch  external  to  the  right  border  of  that  bone.  The  left 
auricle  extends  from  the  upper  border  of  the  fourth  costal  cartilage 
to  the  middle  of  the  second  intercostal  space,  and  in  breadth  it  corre- 
sponds to  the  eighth  dorsal  vertebra  and  its  articulations  with  the  heads 
of  its  ribs ;  its  auricular  appendix  rises  to  the  lower  border  of  the  second 
costal  cartilage. 

The  right  auriculo-ventricular  opening  is  at  the  level  of  the  eighth  dorsal 
vertebra  and  to  the  right  of  the  middle  line  of  the  sternum ;  it  also  extends 
across  slightly  to  the  left  half  of  the  body,  nearly  in  the  centre  between 
the  vertebra  and  sternum.  Anteriorly  its  position  is  marked  by  the  level 
of  the  nipple  and  the  fourth  costal  cartilage. 

The  left  auriculo-ventricular  opening  commences  somewhat  to  the  left 
of  the  sternum  and  reaches  nearly  to  the  middle  line,  lying  2'8  inches 
behind  it  at  the  level  of  the  fourth  intercostal  space. 


PLATE   XII  101 

A  needle  pushed  into  the  middle  of  the  third  intercostal  space,  at  the 
distance  of  rather  less  than  half  an  inch  from  the  left  sternal  border,  would 
strike  the  central  point  of  the  mitral  opening.  In  order  to  pierce  the 
tricuspid  opening,  it  must  be  thrust  into  the  right  half  of  the  sternum  at 
the  level  of  its  articulation  with  the  fourth  costal  cartilage. 

The  pulmonary  orifice  would  be  reached  at  the  upper  border  of  the 
third  costal  cartilage,  about  one  fifth  of  an  inch  external  to  the  left  edge  of 
the  sternum,  and  the  aortic  orifice  at  the  level  of  the  third  costal  cartilage. 

I  have  frequently  performed  such  experiments  on  young  male  subjects, 
and  I  am  convinced  of  the  accuracy  of  these  statements.  But  I  am  far 
from  insisting  on  their  being  absolute  for  all  bodies,  still  less  would  I 
maintain  that  the  positions  are  exactly  the  same  for  the  living  without 
further  observation,  entirely  waving  the  question  of  pathological  changes. 
According  to  the  position  of  the  body  whether  it  lies  on  the  back,  side,  or 
abdomen,  so  the  position  of  the  heart  is  affected,  and  further  it  is  con- 
siderably influenced  by  the  condition  of  the  diaphragm.  The  heart  is  placed 
between  the  lungs  and  the  diaphragm,  so  as  to  be  surrounded  by  structures 
which  can  be  displaced  from  it  as  soon  as  something  else  has  taken  their 
place.  And  owing  to  this  arrangement  the  position  of  the  heart  is  somewhat 
variable.  The  tender  organ  is  not  only  perfectly  protected  from  shocks 
which  affect  the  anterior  wall  of  the  thorax,  but  has,  moreover,  free  room 
for  its  own  movements. 

In  the  body  of  a  young  and  powerful  individual,  such  as  the  one  here 
represented,  the  lungs  gradually  contract  to  an  extent  which  is  never 
the  case  during  life.  Consequently  the  external  air  presses  equally  on  the 
surface  of  the  abdomen  and  upon  the  diaphragm. 

When  the  lungs  contract,  the  heart,  which  lies  between  them,  naturally 
moves  upwards  with  the  diaphragm,  and  so  attains  after  death  a  higher 
level  than  is  possible  during  life. 

If  the  elasticity  of  the  lungs  be  lost,  as  is  the  case  in  old  people  and  in 

* 

those  affected  with   disease  of  the  lung-tissue,  we  must  expect  a  deeper 
position  of  the  heart. 

By  sections  in  the  bodies  of  young  powerful  men  I  found  the  pulmonary 
orifice  at  the  upper  border  of  the  third  left  costal  cartilage,  and  at  the 


102 


PLATE   XII 


level  of  the  sixth  dorsal  vertebra ;  in  persons  of  from  fifty  to  sixty  years 
it  lay  below  the  fourth  costal  cartilage  at  the  level  of  the  eighth  dorsal 
vertebra. 

In  the  event  of  tympanites  the  inflated  intestines  push  up  the  dia- 
phragm and  the  heart  until  the  latter  lies  between  the  yielding  and  more 
contracting  lungs,  so  that  the  pulmonary  orifice  corresponds  to  the  level 
of  the  second  costal  cartilage. 


FIG.  7. 


Adult  male  thorax.     Hydro-pericarditis.     Pirogoff,  ii,  14,  4, 

1.  (Esophagus.    2.  Descending  aorta.    3.  Right  auricle.    4.  Left  ventricle. 
5.  Left  auricle.     6.  Left  ventricle. 


The  diameters  of  the  chest  have  been  discussed  -with  Plates  IX  to 
XII,  and  the  relation  1  :  3  has  been  tolerably  well  established.  It  will 
be  seen  that  these  relations  are  subject  to  essential  changes  in  disease. 
For  the  purpose  of  comparison  I  reproduce  two  of  Pirogoff's  plates  in 
woodcut. 

The  section,  Fig.  1,  is  taken  a  vertebra  higher  than  mine,  consequently 
a  small  portion  of  the  bulbus  aorta3  remains  in  front  of  the  left  auricle,  of 


PLATE    XII 

which  a  considerable  amount  is  left.  The  aortic  portion  of  the  mitral 
valve  is  clearly  seen  lying  stretched  flat  over  the  apex  of  the  hinder  flap. 
The  right  auricle  exhibits  in  its  posterior  half  the  point  of  entrance  of 
the  superior  vena  cava,  which  has  been  somewhat  compressed  by  the  peri- 
cardial  exudation,  and  in  its  anterior  part  is  seen  the  entrance  to  the  right 
ventricle. 

If  these  relations  be  compared  with  the  normal  condition  one  is 
struck  with  the  altered  form  of  the  thoracic  cavity.  The  antero-posterior 
diameter  is  considerably  enlarged ;  it  amounts  to  the  half  of  the  transverse 
diameter,  whereas  it  should  be  only  one  third. 

Owing  to  the  great  distance  of  the  sternum  from  the  spinal  column,  space 
is  permitted  for  the  extensive  exudation.  The  heart  appears  driven  back- 
wards, but  this  is  not  really  the  case,  as  the  parts  between  the  heart  and 
vertebra,  the  ossophagus  and  descending  aorta,  have  clearly  ample  room. 
But  it  is  rolled  over  entirely  to  the  left  side. 

The  axis  of  the  left  side  of  the  heart  passes  in  a  direction  transverse 
to  the  section  of  the  fifth  rib,  whereas  normally  it  points  obliquely  forwards 
towards  the  left  nipple.  The  axis  of  the  right  side  of  the  heart  shows  a 
similar  change  in  direction.  The  lungs  are  considerably  compressed,  to 
give  more  room  for  the  pericardial  exudation.  Whilst  in  my  plate  they 
enclose  the  entire  heart  and  closely  approximate  its  anterior  boundaries, 
they  are  here  widely  separated  from  each  other  and  sunk  back,  not- 
withstanding that  pleuritic  effusion  exists  on  the  right  side.  The 
pleural  cavities  should  be  especially  studied  with  reference  to  paracentesis 
pericardii,  in  opnsequence  of  their  attachment  to  the  chest- wall.  In 
this  section  they  are  but  slightly  dislocated,  only  a  small  space  near 
the  sternum  being  left  free,  so  that  a  trocar  would  have  to  be  intro- 
duced very  close  to  the  border  of  the  sternum  in  order  to  avoid  wounding 
the  pleura. 

The  section  in  *Fig.  2  is  taken  almost  exactly  at  the  same  level  as  mine, 
and  the  relations  of  the  heart  are  similar,  this  organ  being  slightly 
pushed  over,  and  at  the  same  time  rotated  on  its  axis  toward  the  left 
side.  The  left  lung  is  considerably  diminished,  so  that  it  is  not  applied 
to  the  anterior  surface  of  the  heart.  The  pleurae,  however,  reach  as  far 


104 


PLATE   XII 


as  the  sternum,  a  very  small  space  existing  between  them ;  they  exhibit 
so  many  adhesions  (according  to  Pirogoff's  description)  that  the  cavity 
of  the  pleura  was  considerably  interfered  with.  In  addition  to  the  disloca- 


Fm.  2. 


Adult  male  thorax.     Partial  cystic  empyema  of  the  right  side.     Pirogoff,  ii,  11,  2,  £. 

1.  (Esophagus.     2.  Descending  aorta.     3.  Bight  auricle.    4.  Left  ventricle. 
5.  Left  auricle.     6.  Left  ventricle. 

tion  of  the  heart,  the  remarkable  pushing  over  of  the  oesophagus  to  the  left 
side  is  of  interest  ;  but  unfortunately  Pirogoff  gives  no  further  account 
of  this  matter. 


E 
x 

I 


PLATE    XIII 

THE  section  of  which  the  upper  surface  is  here  shown  was  taken 
two  inches  below  the  preceding ;  and  passed  through  the  lower  portion 
of  the  sternum  and  the  fifth  costal  cartilage ;  divided  the  apex  of  the  heart, 
the  diaphragm,  and  the  liver ;  and  came  out  posteriorly  through  the  lower 
portion  of  the  ninth  dorsal  vertebra,  and  the  corresponding  rib. 

This  plate  terminates  the  series  of  sections  of  the  thorax  ;  and  the 
abdominal  cavity  is  already  open,  showing  at  a  glance  how  wounds 
of  the  liver  may  involve  the  lung.  Although  the  left  lobe  of  the  liver  lies 
in  the  section,  a  very  small  portion  only  of  the  left  half  of  the  cupola  of  the 
diaphragm  has  been  removed.  It  rises  as  high  as  the  lower  border  of  the 
fourth  rib,  seen  from  the  front ;  whilst  the  right  half,  of  which  considerably 
more  has  been  removed  than  of  the  left,  rises  as  high  as  its  upper  border — 
nearly  a  rib's  breadth  higher,  and  almost  on  a  level  with  the  plane  of  the 
nipples. 

It  has  been  already  stated  in  the  last  chapter  that  this  position  of  the 
diaphragm  does  not  correspond  with  its  relations  during  life,  but  that  it  was 
so  found  in  the  body  of  a  young  powerful  man,  and  that  it  would  be  pushed 
higher  up  in  tympanitis. 

The  position  of  the  heart  is  in  immediate  relation  with  the  diaphragm 
and  liver ;  and  the  lowest  part  of  the  heart  is  shown  divided  behind  the 
fifth  costal  cartilage  of  the  left  side.  The  absolute  apex  of  the  heart 
is  about  four  fifths  of  an  inch  from  the  plane  of  section.  On  the  right 
side,  in  the  apex  of  the  right  portion  of  the  heart,  is  seen  the  lowest  part 
of  the  cavity  of  the  ventricle,  filled  with  its  columnse  carnese.  At  the 
apex  of  the  left  side  the  section  exhibits  the  arrangement  of  the  muscular 
structure. 

14 


106  PLATE  XIII 

The  heart  does  not  extend  downwards  beyond  the  fifth  rib,  reaching  only 
to  its  lower  border ;  the  cavity  of  the  pericardium,  however,  extends  about 
half  an  inch  lower,  and  contains  about  a  tablespoonful  of  frozen  fluid.  In 
a  male  fifty  years  of  age  I  found  at  the  level  of  the  eleventh  costal  cartilage 
a  portion  of  the  heart  corresponding  with  that  here  represented,  but 
considerably  deeper. 

The  relations  of  the  pleurae  to  the  front  of  the  heart  are  of  practical 
importance.  The  pleuraB  appear  as  folded  sacs,  which  extend  from  the 
anterior  border  of  the  lungs  towards  the  middle  line,  leaving  in  the  present 
instance  merely  a  small  interspace  between  the  left  edge  of  the  sternum  and 
the  fifth  costal  cartilage,  through  which  the  pericardium  could  be  reached 
by  the  trocar  without  wounding  the  pleurae.  Bodies  vary  considerably 
in  this  particular,  so  that  it  is  readily  conceivable  why  so  many  different 
descriptions  are  given  for  the  position  of  the  point  in  the  introduction  of 
the  trocar. 

Luschka,  however,  is  right  when  he  maintains  that  the  pericardium 
presents  at  the  left  border  of  the  sternum  a  narrow  strip  quite  free  of 
pleura,  so  that  it  may  be  safely  avoided  in  paracentesis  of  the  pericardium. 
The  safest  method  of  operating,  as  I  have  satisfied  myself,  is  to  pass  a  fine 
trocar  in  the  upper  angle  between  the  left  edge  of  the  sternum  and  the  fifth 
costal  cartilage.  It  does  not  appear  justifiable  to  depend  upon  an  adhesion 
of  the  pleura.  Even  large  collections  of  fluid  in  the  pericardium  may  exist 
for  a  considerable  time  without  it. 

The  amount  of  extension  of  the  liver  towards  the  left  appears 
surprising ;  hence  the  heart  seems  to  be  entirely  supported  by  its  left 
lobe,  and  from  its  abnormal  size  one  is  inclined  to  assume  that  some 
pathological  condition  was  present.  Such,  however,  was  not  the  case,  and 
the  viscus  was  normal  both  in  weight  and  structure. 

It  must  be  borne  in  mind  that  the  left  lobe  of  the  liver  shows  great 
varieties  of  form  even  under  normal  relations ;  that  it  reaches  down  to  the 
spleen  ;  but  that  it  lies  always  under  the  heart,  a  portion  of  which  projects 
anteriorly  and  to  the  left  side  over  the  margin  of  the  liver.  Again,  it  is  to  be 
remembered  that,  in  consequence,  false  notions  are  formed  of  the  shape  and 
position  of  the  liver ;  one  having  been  accustomed  to  observe  it  in  front  as 


PLATE  XIII  107 

projected  on  a  plane,  in  which  case  its  entire  extent  cannot  be  shown.  A 
good  view  of  the  extent  and  position  of  the  liver  is  obtained  from  the 
diaphragm  above ;  and  this  is  the  easiest  method  that  can  be  adopted  of 
studying  the  important  relations  of  the  liver  to  the  spleen,  stomach,  and 
heart.  I  have  frequently,  after  the  removal  of  the  chest- wall,  shown  the 
diaphragm  intact,  with  a  portion  of  the  pericardium  attached  to  it,  and  sub- 
sequently removed  the  diaphragm  and  introduced  the  liver  into  the  drawing ; 
and  I  always  found  a  similar  relation  of  the  heart  and  liver  to  that  seen  in 
this  plate,  notwithstanding  the  variable  extent  of  the  left  lobe.  If  the  dia- 
phragm be  very  carefully  removed,  the  peritoneum  may  be  preserved  and 
the  individual  organs  seen  through  it  in  their  respective  relations  to  each 
other.  If  the  body  be  placed  in  the  upright  position,  the  pressure  on  the 
surface  of  the  diaphragm  is  lessened  and  rupture  of  the  peritoneal  sac 
avoided.  I  give  three  plates  which  were  made  from  the  bodies  of  young 
powerful  men  (suicides)  which  were  brought  to  the  anatomical  school 
with  the  rigor  mortis  on  them. 

There  is  no  question  that  in  such  operations  the  position  of  the 
diaphragm  frequently  alters ;  and  that  with  the  removal  of  the  upper  half 
of  the  thorax  especially  the  anterior  and  posterior  walls  of  the  lower  half 
somewhat  approach  each  other,  and  the  cupola  of  the  diaphragm  rises 
correspondingly  higher  in  consequence  :  this  alteration  of  position  having, 
however,  but  a  very  slight  influence  on  the  subjacent  organs.  A  prepara- 
tion of  this  kind  may  be  made  on  a  subject  lying  on  the  belly  or  on  the 
back  without  any  perceptible  displacement  of  the  enclosed  viscera. 
Frequent  observations  show  that  by  means  of  this  method  many  useful 
results  are  obtained  in  explanation  of  the  topography  of  this  region.  I 
have,  then,  rested  satisfied  with  the  representations  obtained,  and  have 
refrained  from  attempting  an  improvement  upon  the  plates  by  a  previous 
moulding  in  plaster  of  Paris,  and  from  using  the  drawing  apparatus  of 
Lucee.  Considering  the  sources  of  error  which  result  from  the  relations  in 
the  dead  body,  an  exact  definition  of  the  position  of  the  parts  must  be 
given  up. 

Fig.  1  represents  the  relations  of  the  parts,  the  stomach  being 
tolerably  full.  This  viscus  when  full  pushes  the  left  lobe  of  the  liver 


108 


PLATE  XIII 


outwards,  and  lies  for  the  most  part  covered  by  it.  The  portion  of  the 
diaphragm  that  supports  the  pericardium  indicates  the  position  of  the  heart. 
If  the  left  ventricle,  when  full,  exceeds  the  margin  on  the  left  side, 
it  is  clear  that  the  heart  lies,  not  on  the  stomach,  but  on  the  liver,  and  only 
its  apex  reaches  the  region  of  the  stomach,  and  a  transverse  section 
would  be  similar  to  that  represented  on  Plate  XIII.  The  left  cupola  of 
the  diaphragm  is  distended,  therefore,  by  the  left  lobe  of  the  liver,  stomach, 
and  spleen. 

Fio.  1. 


Normal  position  of  the  viscera  below  the  diaphragm,  viewed  from  above.     J. 

1.  (Esophagus.    2.  Aorta.     3.  Inferior  vena  cava.     4.  Liver.     5.  Pericardial  portion  of 
diaphragm.     6.  Stomach.     7.  Lobulus  Spigelii.     8.  Spleen. 


Fig.  2  represents  the  position  of  the  viscera  below  the  diaphragm  in 
still  greater  distension  of  the  stomach.  By  simple  inspection  of  the  form 
of  the  circumference  of  the  liver,  it  is  evident  that  the  figure  was  taken 
from  another  body,  and  that  a  body  was  used  in  which  there  was  consider- 
able distension  of  the  stomach.  This  distension  was  not  obtained  by  mere 
experiment,  which  very  easily  disturbs  the  relations  of  the  parts  :  the 
subject  was  perfectly  fresh,  and  the  examination  was  made  before  it  was 
touched  in  any  way.  The  stomach,  which  was  distended  with  food,  did  not 
extend  as  far  as  the  left  side,  but  still  had  against  it  the  fatty  portion  of 
the  peritoneum,  which  drags  on  the  left  end  of  the  transverse  colon,  and 
which  is  continuous  with  the  greater  sac. 


PLATE  XIII  109 

The  left  lobe  has  a  different  form  from  that  in  Fig.  1,  notwithstanding 
that  its  relation  to  the  heart  is  the  same,  or,  at  most,  so  slightly  altered 
that  the  apex  of  the  heart,  in  consequence  of  the  greater  breadth  of  the  left 
lobe,  has  liver  substance  on  the  abdominal  surface  of  the  diaphragm  under  it. 
From  observations  that  I  instituted  on  different  subjects,  after  filling  the 
colon  from  the  anus,  or  the  stomach  from  the  oesophagus,  in  order  to 
demonstrate  the  variation  in  position  of  the  organs  in  one  and  the  same 


IX 
Normal  position  of  the  viscera  below  tlie  diaphragm,  viewed  from  above,    f . 

1.  (Esophagus.     2.  Aorta.     3.  Inferior  vena  cava.    4.  Liver.    5.  Pericardial  portion  of 
diaphragm.     6.  Stomach.     7.  Great  oinentum.     8.  Spleen.     9.  Lobulus  Spigelii. 


individual,  I  was  convinced  that  even  by  carefully  lifting  the  peritoneum, 
I  obtained  no  condition  of  things  from  which  a  plate  of  any  value  could  be 
made.  The  stomach  was  much  displaced  from  its  natural  position,  and  was 
emptied  with  as  much  difficulty  as  the  colon ;  so  that  I  was  forced  either  to 
use  different  subjects  for  the  plate,  or  to  select  from  them  those  which  showed 
the  organs  in  the  state  of  distension  desired.  It  appeared  in  the  highest 
degree  remarkable  that  in  a  portion  of  the  trunk,  to  which  merely  the  under 
half  of  the  thorax  was  attached,  one  could  inject  a  large  quantity  of  water 
through  the  oesophagus,  and  leave  it  any  length  of  time  without  its  escaping. 
On  introducing  the  finger  through  the  oesophagus  into  the  stomach  one 


110 


PLATE  XIII 


could  feel  its  wall  between  the  cardiac  extremity  and  the  fundus  jutting 
out  so  sharply  as  to  form  a  distinct  valve.  It  must  remain  for  further 
investigations  how  far  these  relations  on  the  subject  can  be  applied  to  the 
living  body. 

Fig.  3  shows  the  stomach  empty,  and  the  resulting  space  filled  up 
on  the  left  side  by  the  colic  flexure.  The  other  relations  are  similar  to 
the  preceding.  It  appears  in  these  plates  that  the  heart  always  has  the 
left  lobe  of  the  liver  between  it  and  the  stomach,  and  lies  on  the  stomach 
by  only  a  portion  of  its  apex,  which  may  vary  greatly  in  size.  A 


'JZL 


Normal  position  of  the  viscera  below  the  diaphragm,  viewed  from  above.     £. 

1.  (Esophagus.     2.  Aorta.     3.  Vena  cava  interior.     4.  Liver.     5.  Pericardial  portion  of 
diaphragm.     6.  Stomach.     7.  Left  flexure  of  colon.     8.  Spleen.     \. 


frontal  section  shows  the  same  condition,  and  the  order  of  these  struc- 
tures as  arranged  one  above  the  other  can  be  well  studied  (compare  Henke, 
'  Atlas  der  Top.  Anat.,'  tab.  xxxv,  xxxvii,  and  Pirogoff,  I  A,  ii  A,  ii  B). 

It  will  also  be  seen  that,  according  to  the  condition  of  the  stomach,  the 
position  of  the  viscera  in  the  left  cupola  of  the  diaphragm  will  be  altered. 
The  left  flexure  of  the  colon  is  pushed  up  if  filled  with  gas  and  the  stomach 
empty ;  and  will,  as  it  more  often  contains  air  than  the  stomach,  afford 
especially  a  full  tympanitic  percussion  note  in  the  lower  half  of  the  left 


PLATE  XIII 


111 


side  of  the  thorax ;  it  may  also,  by  the  strong  pressure  exerted  upwards, 
disturb  the  functions  of  the  organs  within  the  chest. 

The  following  woodcuts  are  taken  from  Pirogoff's  atlas  to  demon- 
strate the  change  in  the  position  of  the  apex  of  the  heart  as  occasioned  by 
pleuritic  or  pericardial  exudation. 

Fig.  4  illustrates  the  relations  of  the  parts,  at  the  same  level,  when  the 
pericardium  is  very  much  distended  with  fluid.  The  section  is  taken  at 


w 


Male  thorax.     Hydro-pericarditis.     Lungs  healthy.     Pirogoff,  ii,  15,  2.     J. 
1.  (Esophagus.     2.  Aorta.    3.  Vena  cava  inferior.     4.  Liver.     5.  Heart. 


the '  same  level  as  mine,  and   the  apex  of    the  heart  is  pushed  strongly 
backwards  and  somewhat  to  the  left  side. 

The  pleurse  approach  each  other  in  front,  leaving  only  a  narrow  space  at 
the  left  edge  of  the  sternum.  One  would  expect  a  greater  separation  of  the 
pleurae  from  each  other  as  the  quantity  of  fluid  in  the  pericardium  took  up 
greater  space.  It  is  therefore  the  place  to  choose  for  puncture  of  the  peri- 
cardium, as  has  been  stated  before,  so  as  not  to  open  the  pleural  cavity. 
Pirogoff  does  not  mention  the  age  of  the  individual ;  it  is  merely  noticed 
that  the  lungs  (and  very  likely  the  pleurae)  exhibited  no  abnormality. 


112 


PLATE  XIII 


Fig.  5  is  a  section  showing  the  relations  of  the  organs  in  pleurisy  and 
hydropericarditis.  It  was  made  on  the  body  of  a  man  of  middle  age,  who 
died  in  hospital,  and  passes  deeper  than  my  section  by  a  vertebra.  Not- 
withstanding the  mass  of  exudation,  very  little  of  the  liver  is  divided.  As 
regards  the  position  of  the  apex  of  the  heart,  it  is  dislocated  backwards 


FIG.  5. 


Male  thorax.     Left  pleurisy.     Hydro-pei'icarditis.     Pirogoff,  ii,  22,  2.    £. 
1.  (Esophagus.     2.  Aorta.     3.  Yena  cava  inferior.    4.  Liver.     5.  Heart. 


and  to  the  right.     The  distension  of  the  left  pleura  is  so  considerable  that 
it  extends  forwards  to  the  middle  line  and  posteriorly  beyond  it. 

Of  the  ribs  of  the  left  side  almost  the  same  are  divided  as  in  my  case, 
from  which  it  is  evident  that  the  effusion  was  more  considerable,  causing 
a  tilting  up  of  their  anterior  extremities.  On  the  right  side,  on  the  other 
hand,  which,  according  to  PirogofTs  account,  contained  very  little  fluid,  the 
ribs  lie  wider  apart,  so  that  the  fourth  rib  is  sawn  through. 


PLATE  XIII 


113 


Fig.  6  shows  the  relations  of  the  parts  in  double  pleurisy  and  hydro- 
pericarditis.  The  description  is  to  be  found  in  Pirogoff's  atlas,  ii,  p.  54. 

The  section,  which  has  passed  a  vertebra  deeper,  divided  the  fifth,  sixth, 
seventh,  eighth,  and  ninth  ribs  of  both  sides,  and  shows  almost  the  same 
relations  of  the  skeleton  as  Plate  XIII,  both  halves  of  the  thorax  being 
symmetrical.  The  man  had  an  encysted  empyema  of  the  right  side.  The 
right  lung  was  strongly  compressed,  and  appeared  polygonal  in  section 


FIG.  6. 


Male  thorax.     Partial  cystic  empyema  of  right  side.     Hydro-pericarditis.     Pirogoff,  ii,  15,  4.     \. 
1.  (Esophagus.     2.  Aorta.     3.  Yena  cava  inferior.     4.  Liver.     5.  Heart. 

in  consequence.  The  left  pleura  was  thickened  and  very  adherent.  The 
heart,  it  will  be  observed,  is  dislocated  and  drawn  to  the  left.  The  left 
lung  lies  far  back,  and  its  pleural  sac  is  firmly  adherent  for  its  whole 
length  in  front  of  the  heart,  so  that  puncture  of  the  pericardium  could  be 
performed  without  danger  of  the  pleura  at  the  sides.  With  regard  to 
dislocation  and  hypertrophy  of  the  heart,  some  authors  have  frequently 
observed  a  bending  in  of  the  inferior  vena  cava.  (Compare  Luschka, 
'  Anat.,'  i,  2,  p.  445 ;  Bartels,  *  Deutsches  Archiv,'  iv,  p.  269.) 

In  my  opinion  the  question  is  not  yet  decided,  and  can  only  be  definitely 

15 


114  PLATE   XIII 

settled  by  allowing  a  body  to  be  frozen,  and  to  expose  the  right  auricle 
with  the  venae  cavaa  from  behind  with  hammer  and  chisel.  Transverse 
sections,  like  the  one  under  observation,  where  the  vena  cava  and  the 
entrance  of  the  hepatic  vein  are  cut  through  immediately  below  the 
foramen  quadratum,  throw  little  light  on  the  question ;  nor  can  much 
be  expected  from  experiment  or  clinical  observation.  Researches  on 
animals,  which  I  have  instituted  in  Ludwig's  laboratory,  and  published  in 
the  reports  of  the  Academy,  show  that  ligature  of  the  inferior  vena  cava 
does  not  set  up  any  considerable  disturbance  of  the  circulation,  as  the 
blood  finds  a  ready  path  collaterally  by  means  of  the  azygos  veins  and 
spinal  plexus,  thus  getting  into  the  superior  vena  cava. 


PLATE    XIV 

THIS  plate  represents  a  section  through  the  epigastrium,  exposing 
the  liver,  stomach,  and  spleen.  No  more  is  to  be  seen  of  the  lungs ;  the 
black  line  immediately  internal  to  the  ribs  represents  the  pleural  cavity, 
whilst  close  to  it  is  the  diaphragm,  appearing  as  a  muscular  ring.  The 
structures  lying  external  to  it  belong  to  the  thorax,  and  internal  to  the 
diaphragm  is  the  abdominal  cavity. 

The  plate  is  taken  from  the  upper  surface  of  a  section  two  inches  thick 
from  the  same  body  as  the  preceding  and  the  following. 

The  body  of  the  eleventh  dorsal  vertebra  is  seen  divided  near  its 
under  surface,  so  that  a  small  piece  of  the  interarticular  fibro-cartilage  is 
shown.  The  arch  lying  behind  it  also  belongs  to  the  eleventh  dorsal  ver- 
tebra :  the  joint  spaces  in  front  belong  to  the  articular  processes  of  the 
twelfth :  and  on  either  side  are  the  sections  of  the  eleventh,  tenth, 
ninth,  eighth,  seventh,  and  sixth  ribs ;  the  seventh  and  sixth  ribs  being 
divided  twice,  but  not  the  xiphoid  cartilage,  since  the  section  passes  below 
it.  It  appears  strange,  at  first  sight,  that  the  section  of  the  right  half  of 
the  body  should  have  a  larger  area  than  the  left,  the  transverse  diameters 
differing  by  about  half  an  inch;  the  cause  of  this  is,  however,  in  some 
measure,  owing  to  a  want  of  symmetry,  and  also  to  the  fact  that  the  saw- 
blade  diverged  somewhat  from  the  horizontal  plane. 

The  liver  occupies  the  greatest  amount  of  space,  and  is  perfectly 
normal  in  structure  and  weight.  The  left  lobe  of  the  liver  is  prolonged 
into  a  thin  lamina,  which  is  stretched  over  the  stomach  almost  as  far 
as  the  spleen.  This  explains  the  great  extent  of  the  liver  in  the  left  cupola 
of  the  diaphragm,  in  the  preceding  plate.  At  the  point  of  junction  of 
the  right  and  left  lobes,  in  the  left  longitudinal  fossa,  is  the  ligamentum 
teres  in  a  fold  of  peritoneum ;  and  posteriorly,  lying  on  the  diaphragm,  the 


116  PLATE   XIV 

lobulus  Spigelii  with  the  omentum.  Close  to  it  on  the  right  is  the  inferior 
vena  cava ;.  and  in  front  of  this  are  the  transverse  fissure,  the  portal  vein, 
and  the  hepatic  duct. 

The  stomach  contained  some  frozen  food,  which  was  removed  so  as  to 
show  its  walls.  It  was  ascertained  subsequently  that  the  fundus  of  the 
stomach  had  attained  its  highest  position,  and  that  beyond  the  distended 
portion  in  the  commencement  of  the  stomach,  there  was  contraction 
where  the  folds  of  the  mucous  membrane  were  most  marked,  and  that 
subsequently  the  cavity  became  again  distended  further  to  the  right  side 
and  below.  It  appears,  therefore,  that  Luschka  is  quite  correct  in 
disputing  the  entire  approximation  of  the  anterior  and  posterior  walls  of 
the  organ  in  its  empty  condition.  Here  also,  where  completely  normal 
conditions  existed,  the  stomach  was  contracted  like  intestine  in  its  empty 
portions,  and  was  not  flat,  as  represented  in  some  plates. 

The  cut  edges  of  peritoneum  behind  the  stomach  belong  to  its  lesser 
sac.  Further  back  is  the  spleen,  normal,  with  its  blood-vessels  ;  it  corre- 
sponds with  the  course  of  the  ninth,  tenth,  and  eleventh  ribs,  and  in 
its  greatest  diameter  follows  their  direction.  The  left  supra-renal  cap- 
sule is  not  seen,  whereas  the  right  is  evident  between  the  liver  and 
diaphragm. 

Concerning  the  relations  of  the  peritoneum,  it  must  be  remarked  that 
transverse  sections  are  not  adapted  for  displaying  it.  The  cavities  can 
only  be  represented  by  black,  and  the  cut  edges  by  fine  white  lines,  which 
easily  mislead  the  eye. 

In  order  to  render  any  representation  advantageous,  views  of  sur- 
faces must  be  given,  or  longitudinal  or  oblique  sections  taken  as  the 
bases  of  the  drawings,  by  which,  semi-diagramatically,  the  cavities  of  the 
peritoneum  appear  enlarged.  Luschka  and  Henle  have  excellent  plates  of 
this  kind. 

On  the  other  hand,  representations  of  such  transverse  sections,  here 
shown  true  to  nature,  are  of  great  value  surgically.  They  show  what 
localities  are  free  of  peritoneum,  and  what  not,  and  the  surgeon  conse- 
quently can  plan  an  operation.  It  is  of  the  first  importance  to  avoid  this 
membrane,  and  in  this,  as  in  the  following  plates,  the  boundaries  of  the 


PLATE   XIV  117 

cavities  and  points  of  investment  of  the  peritoneum  have  been  represented 
with  the  greatest  fidelity ;  and  hence  the  cavity  of  the  omentum  between 
the  lobulus  Spigelii,  and  the  posterior  wall  of  the  stomach,  was  not  drawn 
as  contracted,  although  both  cavities  are  connected  immediately  below  the 
surface  of  the  section.  The  portion  of  the  stomach  which  lies  close  to  the 
diaphragm  shows  the  end  of  the  posterior  cardiac  region  free,  and  uncovered 
by  peritoneum. 

An  examination  of  the  peritoneum  shows  that  it  has  two  functions  to 
perform,  especially  mechanical,  which  are — (1)  that  it  fixes  the  several 
organs  in  the  abdominal  cavity  in  definite  places;  and  (2),  like  a  colossal, 
sinuous,  mucous  membrane,  allows  of  their  movements  upon  one  another  in 
their  various  conditions  of  distension.  These  changes  of  position  can  occur, 
where  the  black  lines  in  the  plate,  like  joint  spaces,  represent  the  cavities 
of  the  peritoneum ;  at  points,  on  the  other  hand,  where  the  peritoneum  is 
reflected,  and  leaves  a  free  space  for  the  entrance  of  blood-vessels,  the 
viscera  are  fixed  to  their  surroundings. 

In  order  to  show  the  relations  as  they  exist  in  the  extremes  of  age,  I 
have  here  introduced  two  woodcuts.  Fig.  1  is  taken  from  a  man,  get,  50, 
who  had  enlargement  of  the  liver  and  spleen.  Fig.  2  from  a  recent  body 
of  a  female  infant,  at  full  period,  born  dead. 

The  body  of  the  old  man  is  the  same  which  furnished  Plate  IX  in  the 
large  coloured  atlas.  Death  resulted  from  hanging,  and  the  stomach  and 
intestines  were  empty. 

The  section  passed  through  the  tenth  dorsal  vertebra,  and  anteriorly 
through  the  xiphoid  cartilage.  The  stomach  was  empty,  with  the  exception 
of  a  little  frozen  mucus.  The  lung  structure  was  normal  and  absolutely 
empty  of  air.  The  liver  large  and  fatty.  Supra-renal  capsules  and  spleen 
large. 

The  well-developed  body  of  the  child  showed  no  irregularities. 

The  great  resemblance  between  Figs.  1  and  2  is  singularly  remarkable, 
also  the  fatty  livers  of  the  old  and  young  subjects ;  moreover,  the  relations 
correspond  wonderfully  accurately. 

In  both  cases  the  liver  fills  up  almost  the  whole  interspace  internal  to 
the  diaphragm,  and  spreads  over  a  large  portion  of  the  spleen,  which  lies 


118 


PLATE  XIV 


in  relation  to  the  spinal  column,  as  in  Plate  XIV.  The  stomach  alone 
shows  any  important  change  of  position.  In  both  cases  it  is  empty; 
has  the  same  position  between  the  left  lobe,  of  the  liver  and  the  spleen ; 
has  a  portion  of  the  diaphragm  for  a  covering ;  and  is  not  overlaid  by 
peritoneum.  On  the  other  hand  the  shape  is  different  in  the  two  subjects. 


FIG.  1. 


IT 


Male,  set.  50.    \. 
1.  Liver.        2.  Stomach.        3.  Spleen.        4.  Left  lung. 

Whilst  in  the  former  case  the  stomach  is  contracted  like  intestine,  in  the 
latter  it  is  an  oblique  chink ;  so  that  the  anterior  wall  lies  relaxed  on  the 
posterior — a  condition  I  have  never  observed  in  the  adult. 

In  front  of  the  right  supra-renal  capsule  is,  in  the  child,  the  inferior 
cava,  lodged  somewhat  deeper  under  the  lobulus  Spigelii  than  in  the 
other  instance,  where  the  capsules  are  not  seen,  notwithstanding  that  the 


PLATE  XIV 


119 


section  lias  passed  three  vertebrae  lower,  On  the  other  hand,  correspond- 
ing with  the  slight  power  of  contraction  of  the  lungs  in  the  old  man,  they 
are  still  visible  at  the  level  of  the  first  lumbar  vertebra ;  whilst  in  the  youth 
of  twenty-two  years  in  Plate  XIV  the  pleural  cavities  are  empty  at  the 
eleventh  dorsal,  and  in  the  new-born  child,  Fig.  2,  at  the  tenth. 

In  the  new-born  child  the  thorax  is  fixed   at  extreme  expiration,  to 


FIG.  2. 


TJ 


Child,  at  full  period.     Born  dead,     Natural  size. 
1.  Liver.        2.  Stomach.        3.  Spleen.        4.  Supra-renal  capsule. 


which  it  can  never  return  after  the  first  inspiration.  The  entire  contents 
of  the  upper  portion  of  the  abdomen  must  therefore  be  depressed  as  soon 
as  the  diaphragm,  during  the  first  inspiration,  leaves  its  high  position  ;  and 
the  figure,  which  here  lies  three  vertebrae  higher  than  in  the  old  man,  would 
then  take  a  considerably  deeper  level. 

As  in  Plate  XIY  the  space  between  the  liver  and  the  spleen  appears 
to  be  completely  filled  up  by  the  stomach,  which,  however,  presents  only  a 
slight  degree  of  distension,  the  question  arises,  what  would  be  the  condition 
of  things  if  this  viscus  were  more  distended  ?  It  is  easily  seen  that,  apart 


120  PLATE   XIV 

from  a  considerable  protrusion  of  the  anterior  wall  of  the  abdomen,  which 
is  observable  after  each  full  meal,  the  lower  ribs  also  must  give  way — a 
circumstance  which,  under  a  continued  swelling  of  the  abdomen,  leads 
even  to  permanent  prominence  of  the  thoracic  segment,  as  may  be  proved 
in  many  ways,  and  is  especially  seen  in  children.  The  left  lobe  of  the  liver 
must  follow  more  or  less  the  movements  of  the  stomach,  since  it  forms  a 
species  of  covering  to  that  organ ;  it  is  lifted  up  by  the  distended  stomach, 
pushing  the  pericardium  up  with  it,  and  sinks  down  with  the  contracting 
stomach,  the  place  of  which  is  taken  partially  by  the  left  flexure  of  the 
colon.  The  mesentery -like  left  coronary  ligament  of  the  liver  renders  pos- 
sible such  movements  of  its  left  lobe,  which  are  associated  either  with  a 
turning  of  the  entire  liver  (the  axis  of  which  is  to  be  sought  in  the 
right  lobe,  corresponding  with  the  strong,  firm  attachments  to  the  right 
half  of  the  diaphragm),  or  arise  from  the  yielding  or  distension  of  the 
soft  tissues. 

Fig.  3  reduced  from  Pirogoff  will  make  this  relation  clear,  even  if  one 
does  not  obtain  an  entirely  correct  idea  of  the  form  and  position  of  the  left 
lobe  of  the  liver. 

From  this  cut  it  is  clear  that  the  spleen  lies  so  far  back  that  any  deter- 
mination of  its  posterior  limits  by  percussion  is  impossible.  It  is  true 
that  by  percussing  in  a  horizontal  direction  around  the  thorax  towards  the 
spine,  at  the  level  of  the  spleen,  we  obtain  a  different  sound  as  we  approach 
the  spine ;  but  from  the  present  plates  one  would  not  be  warranted  in 
assuming  the  existence  of  an  air-containing  organ  between  the  spleen  and 
the  spine.  We  must  look  for  the  cause  in  the  alteration  of  the  elasticity 
of  the  ribs  at  this  point.  Further,  we  always  find,  if  we  percuss  in  a 
vertical  direction  on  the  back  and  in  the  axilla  from  above  downwards, 
that  the  commencement  of  the  dulness  is  in  a  horizontal  line,  corre- 
sponding with  the  limit  of  the  base  of  the  lung,  and  covering  the  superior 
portion  of  the  spleen,  which  is  directed  obliquely  downwards  and  for- 
wards. One  can  easily  convince  oneself  of  the  firm  position  of  the  spleen, 
which  is  especially  owing  to  the  reflexion  of  the  peritoneum,  under  the 
name  of  phenico-splenic  ligament,  if  the  upper  portion  of  the  thorax 
be  removed  on  the  dead  body,  and  the  sac  of  peritoneum  preserved, 


PLATE   XIV 


121 


so  that  the  liver,  stomach,  left  flexure  of  the  colon  and  upper  wall 
of  the  spleen  are  seen  through  it.  The  stomach  can  be  inflated 
and  again  allowed  to  collapse,  and  the  descending  colon  filled  and  again 
emptied,  when  it  will  be  always  found  that  the  upper  border  of  the  spleen 
is  unchanged  in  position. 

Fia.  3. 


Youth,  set.  15.     Stomach  distended  with  air.     Pirogoff,  iii,  3,  l-$. 
1.  Liver.        2.  Stomach.        3.  Spleen.        4.  Abdominal  aorta.        5.  Vena  cava  inferior. 


On  laying  the  subject  on  the  abdomen  the  spleen  does  not  sink 
forwards,  but  remains  in  its  original  position.  The  relations  are,  how- 
ever, different  when  the  attachments  of  the  spleen  to  the  diaphragm  are 
sparse  or  easily  lacerable,  or  drawn  out  into  long  bands.  This  might 
account  for  the  so-called  movable  spleen. 


16 


PLATE   XV 

IN   this   plate   the    1st  lumbar  vertebra  is  divided  in  the  middle;    on 
the  right    side  are  the  sections   of    the   twelfth,    eleventh,    tenth,    ninth, 
eighth,    seventh,    seventh    and    eighth    ribs,    the    seventh     and    eighth 
being  twice  cut ;    and  anteriorly  the  arches  of  the  cartilages   appear.     On 
the  left  side  the  twelfth  rib  is  absent,  as  from  being  so  short  it  is  not  met 
with   in   the    section,    but   lies   entirely   in  the   preceding   lamina.      This 
section,  like  the  preceding,    exposes  the  upper  portion  of  the  abdomen, 
with  a  part  of  the  spleen,  stomach,  and  a  large  part  of  the  liver.      The 
diaphragm  is  divided  anteriorly  through  its  attachment  opposite  the  seventh 
rib,  near  the  transversalis  muscle ;   afterwards  in  its  free  portion,  so  that 
a  portion  of  the  pleural  cavity  is  seen ;  and  posteriorly  through  its  arch  and 
crura.     The  pleural  cavity,  which  is  clearly  evident  at  the  posterior  wall 
.of  the  trunk,  reaches  further  downwards  there  than  it  does  in  front;   and 
extends  on  the  left  side  to  the  section  of  the  ninth,  and  on  the  right  side  to  the 
seventh  rib.    It  appears  as  a  fine  chink,  which  in  pleurisy  widens  out  into  a 
considerable  cavity,  and  may  hold  a  large  quantity  of  fluid  (about  one  pound) 
before  its  presence  can  be  demonstrated.     A  normal  lung,  however,  may  fill 
up  this  space  in  deep  inspiration. 

Besides  the  rest  of  the  liver,  stomach  and  spleen,  in  the  space  included 
by  the  diaphragm  and  the  transversalis  muscle,  are  seen  the  kidneys, 
pancreas  and  intestines.  The  section,  of  which  the  upper  surface  is  here 
represented,  is  three  and  a  half  inches  below  the  preceding,  its  inferior 
surface  reaching  to  the  navel. 

In  order  to  make  the  cavities  of  the  intestines  clear,  their  frozen  con- 
tents were  with  great  care  broken  loose  before  their  walls  were  thawed 
by  means  of  warm  pincers ;  and  then  the  cavities  accurately  drawn  with 
their  folds  in  the  hardened  condition.  Thus  the  regular  sharply  pro- 


PLATE   XV  123 

jecting  folds  of  Kerkring,  of  the  small  intestine,  and  the  irregular  flat 
processes  of  the  mucous  membrane  of  the  large  intestine,  are  easily  recog- 
nisable. On  the  liver,  on  the  left  side,  anteriorly  and  internally,  is  the 
kidney,  and  the  descending  colon  immediately  below  its  left  colic  flexure, 
which  is  divided  transversely.  The  contents  were  some  green  coloured 
faecal  matter  and  a  little  gas.  Between  the  ascending  colon  and  the  right 
kidney,  is  the  vertical  portion  of  the  duodenum,  divided  transversely  just 
as  it  winds  round  the  head  of  the  pancreas.  The  liver  fills  up  the 
remaining  space  externally  as  far  as  the  diaphragm.  Its  surface  has  the 
impression  of  the  neighbouring  structures.  Its  convex  upper  surface 
attaches  itself  intimately  to  the  line  of  the  diaphragm ;  internally,  on  the 
other  hand,  the  outline  of  the  liver  becomes  irregular,  owing  to  certain 
prominences  in  front  from  the  impression  of  the  colon,  and  behind  from  that 
of  the  kidney — forms  still  recognisable  after  these  organs  have  been  removed, 
but  which,  however,  may  disappear  from  the  equalisation  of  pressure 
within  the  peritoneal  investment.  It  is  open  to  proof  that  the  form  of  the 
liver  is  not  an  independent  one,  but  varies  with  the  pressure  and  volume 
of  neighbouring  organs ;  so  that  in  a  normal  condition  it  must  possess 
a  softness  of  structure  which  can  be  compared  with  fat  and  connective 
tissue,  and  which  yields  to  the  movements  and  change  of  position  of  the 
organs  in  contact  with  it.  A  series  of  sections  of  frozen  bodies  in  the 
region  of  the  liver  should  be  made,  or  the  plates  of  Pirogoff  (fasc.  iii,  1,  2, 
3,  5,  7)  compared,  to  show  that  everywhere  it  is  defined  by  the  neighbouring 
organs,  and  entirely  fills  up  all  remaining  spaces. 

Only  a  small  portion  of  the  spleen  is  seen,  entirely  covered  by  peri- 
toneum, and  at  this  point  nowhere  attached  thereto.  Its  posterior 
extremity  reaches  to  the  section  of  the  eleventh  rib,  and  corresponds  also,  if 
the  preceding  plate  be  examined,  to  the  course  and  curves  of  the  ninth, 
tenth,  and  eleventh  ribs.  Hence  it  agrees  with  what  Luschka  has  recently 
published  ('  Prager  Yierteljahrschrift,'  Bd.  101,  1869,  p.  122). 

In  the  text  to  Plate  XIII  I  have  introduced  three  woodcuts,  figs.  1,  2, 
3,  which  explain  the  position  of  the  spleen,  although  not  originally  with 
this  view.  They  place  its  position  in  the  upper  compartment  of  the 
abdominal  cavity  in  the  cupola  of  the  diaphragm  in  the  different  states  of 


124  PLATE   XV 

distension  of  the  stomach,  and  were  made  from  preparations,  of  which  a  view 
was  obtained  from  above  after  raising  the  peritoneum  by  taking  away  the 
upper  half  of  the  thorax  and  part  of  the  diaphragm ;  and,  although  the 
perspective  view  of  the  position  of  the  spleen  is  not  quite  correct,  it  gives 
the  same  results.  PirogofFs  plates  (fasc.  iii,  B.),  which  represent  plastic 
preparations  made  by  chipping  the  organs  out  of  frozen  bodies  must  be 
compared  with  them.  It  is  shown  in  all  these  figures,  as  Luschka  states, 
that  the  spleen  does  not  occupy  the  highest  point  of  the  cupola  of  the 
diaphragm,  and  moreover  does  not  lie  with  its  hilus  on  the  fundus  of 
the  stomach ;  but  that  the  fundus  of  the  stomach,  covered  by  the  left  lobe 
of  the  liver,  lies  in  the  highest  part  of  the  cupola  of  the  diaphragm,  and 
the  spleen  takes  up  its  position  laterally  with  it.  Correspondingly  with 
the  greatest  amount  of  play  of  the  diaphragm,  the  position  of  the  spleen 
will  not  be  affected ;  and  in  breathing  will  be  less  displaced  than  if  it  lay  high 
up  in  its  cupola  :  at  the  same  time,  the  influence  of  respiration  is  consider- 
able enough  to  be  of  practical  importance.  The  size  of  the  normal  spleen 
cannot  always  be  felt  with  certainty  in  deep  inspiration;  if,  however,  it 
be  enlarged,  it  can  be  reached  with  the  finger,  on  causing  the  individual  to 
take  a  deep  breath.  The  determination  of  the  size  of  the  spleen,  by  per- 
cussion, always  presents  certain  difficulties  which  must  not  be  under-rated. 
Whilst  on  this  subject  I  may  mention  that  the  kidney,  and  left  colic  flexure 
when  distended  with  faeces,  have  more  than  once  been  mistaken  for  tumour 
of  the  spleen. 

A  small  strip  only  of  the  stomach  is  seen  in  front  of  the  seventh  costal 
cartilage.  The  connection  between  the  duodenum  lying  between  the  liver, 
pancreas  and  right  kidney  no  longer  exists.  It  can  be  seen,  however,  from 
the  position  of  the  duodenum  that  the  pylorus  must  have  lain  near  the 
middle  line  of  the  body,  and  so  also  that  the  pyloric  portion  of  the  stomach 
took  an  oblique  direction  from  below  backwards,  hence  the  pyloric  valve 
could  not  have  lain  in  an  antero-posterior  direction  directly,  but  more 
obliquely  forwards  (Luschka).  In  Pirogoff's  Atlas  (iii,  2,  fig.  l),is  a  section 
which  passes  exactly  through  the  pylorus  and  shows  this  relation  clearly. 
According  to  this  plate  the  pylorus  lies  in  the  anterior  half  of  the  abdominal 
cavity  near  the  eleventh  costal  cartilage,  immediately  to  the  right  of  the 


PLATE   XV  125 

* 

middle  line  of  the  body.  It  agrees,  however,  exactly  with  Luschka's  state- 
ment that  the  pylorus  is  not  to  be  sought  in  the  right  hypochondrium,  as  it 
never  reaches  the  right  arch  of  the  ribs ;  and  from  the  present  plate  one 
can  see  that  it  must  have  had  the  same  position.  Hence,  it  follows  that 
the  horizontal  portion  of  the  duodenum  does  not  run  from  left  to  right 
in  a  transverse  direction,  but  more  in  an  antero-posterior  one  between  the 
ductus  choledochus  and  the  gall-bladder,  close  to  the  transverse  fissure  of 
the  liver. 

The  duodenum  is  divided  in  its  vertical  descending  portion  at  the  point 
of  flexure  of  the  upper  horizontal  part.  Between  the  vena  cava  and  the 
pancreas  is  the  ductus  communis  choledochus,  which  has  passed  directly 
over  to  the  left  side  of  the  duodenum,  in  order  to  open  into  the  vertical 
portion  of  the  duodenum  at  the  head  of  the  pancreas.  If  we  look  into 
the  duodenum  we  see  how  it  curves  round  the  head  of  the  pancreas, 
becoming  continuous  on  the  left  side  with  the  inferior  horizontal  portion. 
Owing  to  the  mobility  of  the  stomach,  without  which  the  different  stages 
of  distension  would  cause  great  disturbance,  we  may  expect  that  the 
pylorus  and  the  upper  portion  of  the  duodenum  would  change  with 
its  condition  of  distension.  I  have  proved  that,  whilst  in  the  empty 
stomach  the  pylorus  lies  near  the  middle  line  of  the  body,  in  greater 
distension  it  is  pushed  half  an  inch  further  back.  The  upper  portion 
of  the  duodenum  possesses  a  mesentery  in  the  hepatico- duodenal  liga- 
ment, which  permits  and  follows  its  changes  in  position.  The  middle  or 
vertical  portion  of  the  duodenum  is  not  absolutely  fixed,  but  follows  the 
movements  of  the  ascending  colon ;  and  in  distension  is  pushed  to  the 
left  of  the  middle  line,  assuming  its  original  position  when  the  colon  is 
emptied. 

The  pancreas  is  divided  obliquely,  so  that  a  small  portion  of  the  head 
remains  on  the  left  side  and  a  considerably  larger  portion  on  the  right. 
These  relations  correspond  with  the  position  of  the  pancreas,  as  it  does  not 
lie  exactly  horizontally,  but  passes  obliquely  downwards  from  left  to  right ; 
consequently  the  splenic  vein,  which  lies  below  it,  has  had  its  upper  surface 
removed  in  the  section,  and  the  mouths  of  the  veins  opening  into  it  are 
seen. 


126  PLATE   XV 

The  vein  entering  it  directly  in  the  middle  line  of  the  body  is  the 
superior  mesenteric  ;  and  at  their  junction  the  portal  vein  commences.  This 
position  is  so  constant  that  vertical  sections  in  the  middle  line  would 
expose  a  large  portion  of  it  (Plate  I  and  II).  The  portion  of  the  pancreas 
lying  behind  the  vein  is  the  so-called  lesser  pancreas. 

The  position  of  the  pancreas  at  the  level  of  the  first  lumbar  vertebra, 
corresponds  with  that  in  Plate  I  and  II ;  it  is,  however,  so  increased  in 
breadth  that  it  extends  downwards  to  the  next  vertebra. 

Behind  the  pancreas  on  the  right  side  is  the  vena  cava,  with  the  left 
renal  vein  opening  into  it,  and  near  it  on  the  left  side  the  abdominal  aorta. 
In  front  of  the  latter  passes  the  superior  mesenteric  artery,  in  order  to  gain 
the  root  of  the  mesentery  beneath  the  gland. 

The  aorta  has  nearly  reached  the  middle  line,  where  it  divides  below 
the  third  lumbar  vertebra  into  the  common  iliac  arteries.  Its  distance  from 
the  anterior  wall  of  the  abdomen  is  nearly  four  and  a  half  inches ;  whilst 
the  distance  in  the  preceding  Plate  at  the  level  of  the  eleventh  dorsal 
vertebra,  in  the  same  body,  is  nearly  five  inches. 

In  plate,  No.  XYI,  corresponding  with  the  cartilage  between  the  third 
and  fourth  lumbar  vertebra,  this  distance  is  only  three  and  a  half  inches ;  so 
that  it  is  clearly  evident  that  the  anterior  curvature  of  the  lumbar  spine 
brings  the  vessel  nearer  the  abdominal  wall,  rendering  its  compression  from 
the  front  possible. 

The  section  of  the  kidneys  is  such  that  it  cuts  the  right  above  its  hilus, 
whilst  on  the  left  side  it  has  passed  through  it.  The  left  kidney  lies  a  little 
higher  than  the  right — a  relation  which  exists  in  the  generality  of  cases. 
The  length  of  the  kidneys  corresponds  with  the  bodies  of  three  and  a  half 
vertebras,  they  extend  from  the  upper  border  of  the  twelfth  dorsal  vertebra 
to  the  middle  of  the  third  lumbar.  As  they  are  in  relation  with  the  spleen 
and  liver  superiorly,  and  are  bounded  posteriorly  by  the  diaphragm  and 
pleural  cavity,  one  would  expect  that  they  would  be  displaced  in  great  pleu- 
ritic effusion  by  the  descent  of  the  diaphragm  as  are  the  liver  and  spleen. 
Enlargements  of  the  liver  exert  a  dislocating  effect  upon  the  kidney,  as 
will  be  shown  more  exactly  in  the  next  plate. 

The  position  of  tne  kidneys  is  rather  antero-posterior  than  transverse, 


PLATE   XV  127 

the  hilus  being  turned  more  forwards  than  inwards.  According  to  Luschka, 
lines  which  pass  through  the  hilus  corresponding  with  the  greatest  breadth 
of  these  organs  intersect  if  produced  forwards,  at  an  angle  of  60°  in  front 
of  the  middle  of  the  first  lumbar  vertebra — a  statement  which  corresponds 
tolerably  with  the  relations  seen  of  the  present  plate. 


PLATE    XVI 

THE  section  in  this  case  passes  through  the  navel  dividing  the  soft  parts 

just  above  the   iliac  crest,   and  the   inter- vertebral   space    between   the 

third  and  fourth  lumbar  vertebras.      The  ribs  are  no  longer  seen,  and  the 

section  is  now  below  the  thorax  and  through  the  middle  of  the  abdomen. 

The  walls   of  the  abdominal  cavity  are  formed,   anteriorly  and  laterally 

entirely  by  the  three  oblique  muscles,  behind  by  the  quadratus  lumborum 

and  the  strong  ligaments  together  with  the  psoas  magnus  of  both  sides. 

The  posterior  wall,  where  no  spinous  processes  are  visible,  is  very  thick 

and  strong,  and  formed  by  the  mass  of  the  dorsal  muscles.     The  contents 

of  the  abdominal  cavity  are  the  great  vessels  and  ureters,  the  ascending 

transverse  and  descending  colon,  and  the  small  intestines.     The  contents  of 

the  intestines  were  carefully  removed  in  order  to  allow  of  these  viscera 

being  accurately  represented  in  situ.     The  section  is  from  the  same  body 

as  the  preceding,  and  is  taken  about  two  inches  lower  down. 

Before  explaining  the  details  here  represented,  I  have  to  make  some 
few  remarks  on  the  kidneys.  They  lie  entirely  above  this  section  and 
within  the  region  of  the  ribs,  higher  than  is  frequently  supposed,  and  as 
many  are  accustomed  to  seek  them.  Hence  their  position  may  be  consi- 
dered as  an  independent  one  as  regards  the  movements  of  the  diaphragm 
or  enlargements  of  the  liver  and  spleen.  I  think  I  can  prove  that  in  both 
respects  the  relations  are  otherwise,  and  that  the  position  of  the  kidneys 
is  unchangeable. 

Both  kidneys  extend  over  the  bodies  of  three  and  a  half  vertebras,  and 
reach  from  the  upper  border  of  the  twelfth  dorsal  downwards  to  the  middle 
of  the  third  lumbar  ;  and  it  is  to  be  remarked  that  they  do  not  lie  exactly  on 
the  same  level,  but  that  the  left  rises  somewhat  higher  than  the  right. 


PLATE   XVI  129 

According  to  Luschka  (Anat.,  ii,  1,  p.  289),  they  usually  lie  higher,  viz. 
from  the  middle  of  the  eleventh  dorsal  to  the  lower  border  of  the  second 
lumbar  vertebra.  I  do  not  lay  any  stress  on  this,  and  I  think  that  these 
statements  may  be  regarded  as  coinciding  with  mine,  since  half  a  vertebra 
makes  but  little  difference.  The  hilus  lies  at  the  level  of  the  first  lumbar 
vertebra,  and  corresponding  with  it  is  the  position  of  the  renal  vessels  in 
Plates  I  and  II.  Pirogoff  gives  the  same  (fasc.  iv,  tab.  4 — 9) ;  but  through 
the  hilus  in  front  of  the  first  lumbar  vertebra.  The  upper  margin  within 
which  the  kidneys  are  divided  is  determined  by  the  eleventh  dorsal  vertebra ; 
the  lower  by  the  cessation  of  the  section  of  the  ribs,  and  corresponds  nearly 
with  the  third  lumbar  vertebra. 

But  the  relations  are  different  if  there  be  depression  of  the  diaphragm, 
or  enlargement  of  the  liver  and  spleen.  The  kidneys  are  then  pushed  out  of 
their  position,  and  undergo  a  dislocation,  which  may  amount  to  the  extent  of 
several  vertebras.  In  a  pleuritic  exudation  of  the  right  side  no  kidney  is  to 
be  seen  at  the  middle  of  the  twelfth  dorsal  vertebra,  Pirogoff  (iii,  6,  3)  :  and 
in  the  man  of  fifty  years,  with  enlargement  of  the  liver  and  spleen  as  I  have 
before  mentioned,  the  hilus,  as  in  the  woodcut,  fig.  1,  is  met  with  at  the  level 
of  the  fourth  lumbar  vertebra.  The  kidneys  were  also  here  directly 
pushed  downwards  on  to  the  soft  parts. 

As  regards  the  intestines,  in  Plate  XYI,  the  inferior  portion  of  the 
colon  is  in  front ;  behind  and  on  the  left  side  the  contracted  descending 
colon ;  posteriorly  and  on  the  right  the  ascending  colon  more  distended. 

Both  the  ascending  and  descending  colon  lie  in  the  angle  formed  by 
the  psoas  magnus  and  quadratus  lumborum.  More  in  the  middle  of 
the  cavity  of  the  abdomen  are  coils  of  small  intestine,  though  not  so 
many  as  one  might  expect.  From  the  descending  colon  to  the  anterior 
border  of  the  transverse  colon  is  seen  the  cut  surface  of  the  great  bag  of 
the  peritoneum  passing  across  to  the  ascending  colon. 

It  is  remarkable  that  the  intestines  should  show  such  extreme  differ- 
ences in  calibre.  According  as  they  are  empty,  full,  or  distended  with 
gas,  they  exhibit  a  larger  or  smaller  cut  surface.  The  ascending  and 
transverse  colons  are  large,  and  so  also  is  a  coil  of  small  intestine,  which 
has  considerably  compressed  the  end  of  the  latter. 

17 


130 


PLATE   XVI 


The  other  portions  of  the  small  intestine  are  only  slightly  distended ; 
and  the  descending  colon  is  nearly  empty. 


FIG.  1. 


Male,  set.  50.     Dislocation  of  the  kidneys.     £. 

1.  Kidney.    2.  Vena  cava  inferior.    4.  Abdominal  aorta. 

The  vertebra  shown  is  the  fourth  lumbar. 


The  following  woodcut  from  Pirogoff  (iii,  10,  1),  which  represents  all 
the  intestines  fully  distended,  does  not  correspond  with  the  natural  state 
of  things,  but  is  the  result  of  excessive  and  equally  distributed  artificial 
distension. 

Pirogoff  states  that  by  inflating  the  intestines  of  a  subject  in  all  respects 
normal,  before  freezing  it,  he  has  completely  distended  the  abdomen. 

The  external  contour  of  the  abdominal  walls  corresponded  with  this 
artificial  distension  of  the  intestines.  This  contour  is  almost  in  the  form  of 
a  circle,  whereas  mine  corresponds  with  the  normal  relations,  and  presents 


PLATE   XVI 


131 


a  flat  oval.     It  will  be  observed  from  the  condition  of  the  oblique  muscles 
how  considerably  the  distension   of  the  abdominal  walls  has  compressed 

FIG.  2. 


Male  adult.     The  intestine  inflated  with  air  and  greatly  distended.     Pirogoff,  iii,  10,  1.  5. 

1,  1.  Inferior  margins  of  the  kidneys.     2.  Abdominal  aorta.     3.  Inferior  vena  cava. 
4.  Ascending  colon.     5.  Descending  colon. 


them ;  and  we  can  estimate  from  their  stretching  and  thinning  the  form 
they  must  assume  in  pregnancy,  ovarian  tumours  and  ascites,  and  regulate 
the  depth  of  an  incision  when  required. 

We  must  notice  the  position  of  the  spinal  column.  As  in  Plate  XYI 
the  intervertebral  substance  lies  nearly  in  the  middle  of  the  circle,  while  in 
PirogofFs  plate  the  position  of  the  vertebra  is  far  behind  it. 


132  PLATE   XVI 

The  distance  of  the  anterior  wall  of  the  abdomen  from  the  spine  in 
Plate  XVI  is  nearly  3  inches ;  in  fig.  1,  2*5  inches ;  and  in  Pirogoff  s  nearly 
6  inches, — the  section  passing  immediately  below  the  navel. 

A  less  distance  between  the  spine  and  the  abdominal  walls  than  that 
shown  in  Plate  XVI  is  not  uncommon.  This  depends  on  the  position 
of  the  diaphragm  and  the  contraction  of  the  lung  on  the  one  hand,  and 
on  the  distension  of  the  intestines  on  the  other  :  and  it  is  easily 
understood  how,  with  normal  lungs  and  empty  intestines,  the  abdomen  in 
the  dead  body  can  be  pressed  in  so  much,  and  the  lumbar  vertebra  present 
such  a  marked  prominence  through  the  abdominal  walls,  the  distance  being 
thus  reduced  to  a  minimum. 

Therefore,  in  compressing  the  abdominal  aorta,  care  must  be  taken  to 
obtain  a  high  position  of  the  diaphragm,  and  that  the  intestines  be  as 
empty  as  possible.  This  compression  is  indispensable,  for  example,  in 
disarticulation  of  the  head  of  the  thigh-bone.  Pressure  must  be  brought 
to  bear  immediately  in  the  region  of  the  navel,  as  the  aorta  divides  just 
below  the  umbilicus,  and  still  further  downwards  the  finger  would  fall 
into  the  pelvis. 

Lying  near  is  the  aorta  in  the  middle  line,  and  the  cava,  which  is  more 
to  the  side,  also  the  ureters,  and  close  to  them  and  more  externally  the 
spermatic  vessels.  Behind  and  partly  internal  to  the  psoas  are  the  sec- 
tions of  the  lumbar  nerves. 

The  oblique  muscles  are  divided  immediately  above  the  crest  of  the 
ilium.  The  relations  of  their  tendons  to  the  sheaths  of  the  rectus 
abdominis  and  quadratus  lumborum  are  so  clearly  shown  in  the  plate 
that  we  need  not  refer  to  them  again.  The  anterior  iliac  spines  spring 
forward  as  projections  in  the  external  contour. 

It  remains  now  to  describe  the  position  of  the  descending  colon,  and 
the  operation  for  opening  it,  which  is  practicable  in  this  region  without 
wounding  the  peritoneum.  This  proceeding  was  described  by  Callisen,  but 
was  first  performed  by  Amussat  in  1839,  and  it  afterwards  obtained  the 
name  of  Callisen- Amussat 's  operation  for  artificial  anus. 

This  operation  is  preferred  by  most  surgeons  to  that  of  opening  the  iliac 
flexure  in  the  left  inguinal  region  (Littre),  as  the  descending  colon  has 


PLATE   XVI  133 

a  fixed  position,  and,  being  incompletely  invested  by  peritoneum,  an  incision 
can  be  made  into  it  without  wounding  this  membrane.  It  is  usually  stated 
that  the  descending  colon  lies  along  the  outer  border  of  the  quadratus 
lumborum  ;  and,  in  conformity  with  this,  an  incision  is  to  be  made  vertically 
along  the  outer  border  of  this  muscle.  This  is  not  always  correct.  At 
the  lower  border  of  the  kidney  the  colon  lies  further  outwards  than  it  does 
in  the  neighbourhood  of  the  ilium ;  and,  the  quadratus  lumborum  being 
narrower  above  than  below,  the  rule  is  true  as  far  as  regards  the  level  of 
the  third  lumbar  vertebra,  but  not  so  for  the  deeper  regions.  At  the  level  of 
the  symphysis  between  the  third  and  fourth  vertebra,  and  at  the  fourth 
below  the  kidney — and  therefore  exactly  in  the  field  of  operation — the 
quadratus  lumborum  covers  in  the  colon  posteriorly,-  and  must  be  cut 
in  order  to  reach  it.  It  is  only  when  much  distended,  a  condition 
which  is  not  so  constant  as  one  would  expect  in  operations,  that  the 
intestine  increases  in  breadth  forwards  and  inwards,  or  overlaps  the 
outer  border  of  this  muscle  (PirogofF,  iii,  B.,  tab.  14).  Consequently  the 
incision,  which  is  to  be  directed  along  the  border  of  the  great  extensors  of 
the  trunk  from  the  ilium  to  the  twelfth  rib,  would  divide  the  strong 
tendons  of  the  transversalis  until  the  quadratus  is  exposed,  and  subse- 
quently the  fibres  of  this  muscle,  when  the  extra-peritoneal  fat  and  cellular 
tissue  would  be  met  with. 

When  the  surgeon  has  carefully  arrived  at  the  cellulo-fatty  tissue  through 
the  fascia  beneath  the  quadratus  lumborum,  making  the  incision  of  an  equal 
length  with  the  primary  one,  so  as  to  avoid  a  funnel-shaped  wound,  the  main 
point  is  to  fix  the  colon  at  its  free  surface  and  to  open  it.  In  doing  so  he 
must  avoid  the  kidney,  which  from  its  deep  position  (cf.,  fig.  1)  can  easily 
obstruct  the  field  of  operation,  and  which  must  therefore  be  carefully 
pushed  on  one  side.  From  the  impossibility  of  recognising  the  peritoneum 
from  its  posterior  aspect,  success  can  only  be  safely  calculated  on  by 
measuring  the  distance  of  the  point  of  reflection  of  the  peritoneum,  and 
how  far  from  the  colon  this  position  is  constant. 

In  the  first  place,  as  regards  the  descending  colon,  which  I  here 
particularly  refer  to,  after  measurements  on  frozen  bodies  of  full  grown 
men,  I  find  that  this  distance,  in  a  straight  line  (therefore  not  corre- 


134  PLATE   XVI 

spending  with  the  curvature  of  the  wall  of  the  intestine),  is  from  four 
fifths  of  an  inch  to  one  inch,  supposing  the  intestine  empty  and  con- 
tracted (at  a  level  between  the  third  and  fourth  lumbar  vertebraa) ; 
further,  that  the  free  side  of  the  intestine,  as  in  Plate  XVI,  does  not 
look  posteriorly  but  somewhat  inwards,  exactly  towards  the  angle  which 
the  psoas  and  quadratus  lumborum  make  with  each  other.  If,  on  the 
otheiv  hand,  the  small  intestines  are  much  distended,  the  peritoneum 
between  the  psoas  and  colon  would  be  pushed  further  downwards ;  and 
the  colon,  by  means  of  the  traction  of  the  parietal  portion  of  the  perito- 
neum, would  be  rotated  on  its  axis,  so  that  its  free  surface  would  be 
directed  more  outwards. 

Should  the  colon  itself  be  distended,  its  surface  free  of  peritoneum 
becomes  considerably  larger,  and  may  assume  a  breadth  of  from  2  to  2' 5 
inches.  Tympanitis  of  the  small  intestine  appears  to  have  a  rotatory 
influence  on  the  distended  colon ;  and  on  comparing  Pirogoff's  plates  it  is 
shown  with  its  free  surface  turned  somewhat  outwards  (cf.  Pirogoff,  iii, 
B,  tab.  xiv). 

In  the  performance  of  the  operation  of  colotomy  a  distended  abdomen 
will  probably  often  be  met  with.  I  therefore  do  not  consider  these  remarks 
superfluous,  and  I  hope  that  they  may  contribute  to  make  the  avoidance  of 
the  peritoneum  more  certain  than  heretofore  where  it  was  so  much  left  to 
chance ;  and,  as  a  third  part  of  the  cases  show  wound  of  this  membrane,  the 
value  of  Amussat's  method  appears  problematical. 


PLATE    XVII 

IN  order  to  bring  the  pelvic  organs  into  view,  a  section  was  made  of 
the  trunk  just  over  the  symphysis  pubis,  and  through  the  lower  portion  of 
the  sacrum.  The  section  passed  through  the  inguinal  region,  the  outer 
mass  of  the  muscles  of  the  thigh,  the  head  of  the  thigh  bone  near  its 
middle,  the  pelvis,  bladder,  rectum,  and  some  coils  of  intestine  lying  in 
Douglas's  pouch.  The  ischia  were  divided  in  the  tuberosity,  so  that  the 
section  nearly  followed  the  sacro-spinous  ligament. 

The  plate  moreover  shows,  enclosed  in  the  bony  pelvis,  the  obturator 
internus  and  levator  ani  muscles,  and  laterally  the  ilio-femoral  articulation 
with  its  muscles  and  vessels. 

We  notice  at  first  that  the  central  portion  is  bounded  by  the  pubis, 
ischium,  levator  ani,  sacro-spinous  ligament,  and  the  last  portion  of  the 
sacrum. 

The  bladder,  which  contained  about  four  ounces  of  frozen  urine, 
appeared  so  contracted  on  its  contents  that  its  form  was  not  affected  by 
the  pressure  of  the  neighbouring  organs,  as  is  so  frequently  observed  in 
Pirogoff's  plates,  whence  the  upper  wall  appears  considerably  fallen  in. 
The  body  was  perfectly  fresh  when  brought  in  for  preparation,  and  as  no 
decomposition  had  set  in  gas  had  not  formed,  so  that  the  forms  of  the 
cavities  were  not  changed.  The  contents  of  the  bladder  were  removed 
before  the  drawing  was  made.  The  internal  orifice  of  the  urethra  is 
clearly  seen  in  the  middle  of  a  fringe  formed  by  folds  of  mucous  mem- 
brane. More  in  front  is  the  anterior  wall  of  the  bladder,  flattened  by 
the  pressure  of  the  symphysis.  The  thickness  of  the  wall  of  the 
bladder,  considering  the  amount  of  distension,  is  considerable.  The 
thickness  of  the  posterior  wall,  however,  is  due  to  its  having  been  cut 
obliquely.  In  order  to  compare  the  position  and  form  of  the  bladder  with 


136  PLATE   XVII 

the  section  given  in  Plate  I,  the  mass  of  ice  was  carefully  removed  and 
represented  in  profile.  This  could  readily  be  accomplished,  as  only  a  small 
part  of  the  upper  wall  of  the  bladder  and  its  contents  was  removed  with 
the  upper  portion  of  the  section.  By  comparing  this  with  the  sagittal  section 
of  Plate  I  a  close  agreement  in  form  was  observed  ;  though  they  differed 
in  the  fact  of  the  internal  orifice  of  the  urethra  in  Plate  I  being  somewhat 
higher  than  in  this.  In  both  cases,  however,  the  form  and  position  of  the 
bladder  of  a  young  powerful  man  is  defined,  as  can  be  verified  by  injecting 
tallow  either  by  the  urethra  or  the  ureters.  It  is,  at  least,  certain  that  the 
spherical  form  represented  by  Kohlrausch  is  not  a  natural  condition,  as  he 
omits  to  notice  a  neck  to  the  bladder,  which  is  a  funnel-shaped  contraction 
of  this  viscus  towards  the  urethra.  For  a  wider  distension  of  the  bladder 
there  is,  as  the  plate  shows,  ample  room.  The  cellulo-fatty  tissue  on 
both  sides  of  it  gives  way  readily,  and  the  coils  of  small  intestine  are 
easily  lifted  up  and  pushed  on  one  side  by  the  swelling  bladder. 
The  rectum  will  be  more  flattened,  and  room  is  afforded  by  the 
emptying  of  great  venous  plexuses,  until  at  last  the  bladder  alone 
almost  fills  the  pelvic  cavity.  With  these  changes  in  volume  of  the 
bladder,  the  relations  of  its  peritoneal  coat  alter.  Even  in  the  slight 
degree  of  distension  shown  in  the  present  instance,  only  the  upper  wall  and 
a  small  portion  of  the  posterior  were  covered  by  peritoneum,  so  that  there 
was  a  passage  above  the  symphysis  although  but  a  slight  one ;  and  it  is 
evident  that  this  sub-peritoneal  passage  must  acquire  breadth  with  the 
increased  distension  and  elevation  of  the  bladder.  Behind  the  bladder  is  a 
flat  section  of  the  peritoneal  sac  containing  a  portion  of  small  intestine 
divided  behind  the  fold  of  Douglas,  and  behind  this  again  is  a  cul-de-sac  of 
peritoneum,  the  so-called  pouch  of  Douglas.  This  is  directed  in  an 
oblique  direction  forwards  and  downwards,  and  is  about  three  fourths  of  an 
inch  deep.  It  held  about  three  fifths  of  an  ounce  of  frozen  water. 

The  vesiculae  seminales,  which  lie  immediately  below  the  section,  were 
exposed  by  taking  away  some  cellular  tissue ;  towards  the  middle  line 
the  vasa  deferentia  take  a  sharp  curve  forwards  and  upwards,  and  are 
divided  in  the  section ;  their  small  calibre  and  thick  walls  are  well  seen. 
Anteriorly  and  somewhat  externally,  are  the  ureters  in  section.  The 


PLATE   XVII  137 

rectum,  which  contained  a  little  faeces,  was  divided  shortly  before  its  final 
curve.  The  anal  extremity  was  fully  3-8  inches  distant  from  it.  If  the 
peritoneum  leaves  the  anterior  surface  of  the  rectum  entirely  free,  and, 
under  the  form  of  Douglas's  pouch,  descends  here  externally  and  internally 
rather  more  than  half  an  inch  ;  this  pouch  is  about  three  inches  from 
the  anal  aperture,  and  it  follows  that  at  this  level  an  operation  on  the 
rectum  might  be  undertaken,  without  fear  of  wounding  the  peritoneum. 
These  relations  correspond  with  those  of  Plate  I. 

The  question  arises  with  regard  to  the  rectum,  as  in  the  case  of  the 
bladder,  what  changes  of  form  it  assumes  with  its  varying  degrees  of  disten- 
sion ;  that  it  is  capable  of  very  great  changes  in  volume,  both  experience  and 
experiments  by  means  of  injection  show  us.  The  requisite  space  is 
provided  for  in  the  same  way  as  for  the  bladder ;  the  cellular  tissue  and  fat 
are  pushed  aside,  Douglas's  pouch  and  the  intestines  are  lifted  up,  and  in 
fuller  distension  of  the  rectum  the  bladder  is  raised  somewhat  upwards  and 
forwards.  The  following  woodcut  from  Pirogoff's  atlas  is  instructive  on 
this  point. 

There  is  little  here  that  needs  explanation  ;  the  great  similarity  in  form 
with  my  plates  will  facilitate  the  description.  More  than  half  the  cavity  of 
the  pelvis  is  occupied  by  the  distended  rectum,  which  is  cut  through  about 
two  inches  above  the  anus,  and  is  considerably  distended  with  air.  The 
semi-lunar  fold  has  not  been  obliterated  by  this  distension,  but  springs  up 
sickle-shaped  into  the  cavity.  The  contour  of  the  pelvic  cavity  is  worthy  of 
notice.  The  section  passes  as  above  mentioned  through  the  spines  of  the 
ischia,  and  partially  through  the  sacro-spinous  ligaments,  and  between 
the  ischiatic  notches.  Corresponding  with  it,  a  process  of  bone  springs 
from  the  body  of  the  ischium  on  both  sides,  tolerably  far  backwards, 
and  terminates  in  the  whole  length  of  the  sacro-spinous  ligament  as  far  as 
the  sacrum.  On  the  right  side  this  band  is  only  to  be  followed  for  a  certain 
distance  from  the  sacrum,  and  does  not  reach  to  the  apex  of  the  ischium 
as  on  the  left ;  while  the  sacro-spinous  ligament  has  a  horizontal  direction, 
the  tuberoso-sacral  ligament  has  a  more  vertical  one,  and  a  small  portion 
only  of  the  latter  is  seen.  It  is  shown  near  the  sacrum  at  the  edge  of  the 
gluteus,  where  it  deviates  from  the  other  ligamentous  band  and  lies  deep. 

18 


138 


PLATE   XVII 


Between  these  fasciculi,  on  the  left  side,  lie  the  internal  pudic  vessels  and 
nerves ;  on  the  right  they  are  further  off,  and  are  to  be  looked  for  near 
the  spine  of  the  ischium.  Internally  on  either  side  from  the  sacro-spinous 
ligament  is  a  dark  band,  partly  prolonged  to  the  spine  of  the  ischium  and 
partly  associated  with  the  fascia  of  the  obturator  internus;  this  is  the 
superior  portion  of  the  levator  ani.  This  muscle  closes-in  the  cavity  of 
the  pelvis  like  a  muscular  funnel,  and  consequently  may  not  be  inaptly  com- 


Fia.  1. 


Transverse  section  of  the  pelvis  of  a  boy,  set.  15.     Pirogoff,  fasc.  iii,  tab.  xvi,  fig.  1. 

1,1.  Head  of  femur.     2,2.  Great  trochanter.     3.  Tip  of  coccyx.    4.  Rectum  distended  with.  air. 

5.  Bladder.    6.  Upper  border  of  symphysis  pubis.     7,  7.  Spermatic  cord.    8, 8.  Femoral 

vessels.     9,  9.  Obturator  internus.     10, 10.  Gluteus  maximus. 


pared  to  the  diaphragm.  All  sections  which  divide  the  bladder  further 
downwards  must  therefore  fall  within  the  region  of  this  muscle,  and  expose 
it  as  a  muscular  ring  limiting  the  pelvic  organs.  Such  a  section  is  shown 
in  the  following  figure. 

Fig.  2  represents  a  section  that  I  made  on  the  pelvis  of  an  old  man.  It 
passes  through  the  symphysis;  on  the  left  side  through  the  lesser  sacro- 
sciatic  foramen ;  on  the  right  somewhat  lower,  through  the  tuberosity  of  the 
ischium ;  and  posteriorly  through  the  tip  of  the  coccyx.  The  levator  ani  is 
seen  bounding  the  pelvic  cavity,  which  contains  behind  the  rectum  a  coil 


PLATE   XVII 


139 


of  small  intestine,  the  vesiculse  seminales,  and  the  neck  of  the  bladder  and 
urethra. 

Since  this  section  is  taken  considerably  deeper,  the  left  gemellus 
inferior  is  seen  running  in  direct  relationship  with  the  obturator  internus 
muscle ;  notwithstanding  this,  Douglas's  pouch  with  its  peritoneum  is 
present.  It  thus  appears  that  the  position  of  the  peritoneal  sac  is  deeper 
in  the  present  one  than  on  the  young  subject  shown  in  fig.  1. 

If  we  consider,  moreover,   that  in  new-born  children  the  position  of 


FIG.  2. 


Transverse  section  of  the  pelvic  cavity. 

1,1.  Head  of  femur.     2.  Rectum.     3.  Bladder.    4,4.  Femoral  vessels. 
5.  Apex  of  coccyx.     6.  Gluteus  maximus. 


the  peritoneum  relatively  within  the  pelvis  is  particularly  high  this 
relation  must  be  described  as  natural  and  corresponding  with  advanced 
age ;  and  hence  one  must  be  particularly  careful,  in  operations  on  the 
rectum  in  old  people,  not  to  wound  the  peritoneum,  which  extends  lower 
down  than  in  younger  individuals. 

Fig.  3   is   reduced   from    Pirogoff's   atlas.      It   is    stated  in  the    text 


140 


PLATE   XVII 


(fasc.  iii,  p.  59)  that  it  was  from  the  body  of  a  full-grown  man,  whose 
bladder  and  rectum  were  full.  The  section  passed  through  the  lowest 
portion  of  the  symphysis,  about  seven  lines  below  its  upper  border,  through 
the  foramen  ovale,  the  tuber  ischii,  near  the  lesser  sciatic  notch  and  the 
insertion  of  the  sacro-sciatic  ligament,  and  included  the  coccyx  posteriorly. 
The  lower  half  of  the  section  is  represented,  so  that  it  is  viewed  from  above 
downwards. 

In  such  a  section,  a  clear  view  of  the  levator  ani  cannot  be  given,  at 


FIG.  3. 


Section  of  the  lower  portion  of  the  pelvis  of  a  full-grown  man,  with  distended  rectum. 

Pirogoff,  iii,  16,  3. 

1,1.  Head  of  femur.    2.  Rectum.    3.  Bladder.    4.  Femoral  vessels.    5.  Tip  of  coccyx. 

6,  6.  Gluteus  maximus. 


least  not  with  respect  to  its  physiology,  as  only  a  small  portion  of  its  fibres 
would  be  divided.  It  will  be  clearly  seen  at  the  same  time  that  when 
the  rectum  is  full  Douglas's  pouch  and  the  lower  coils  of  the  smaller 
intestine  are  lifted  up.  Between  the  bladder  and  rectum  lie  the 
sections  of  the  vesiculse  seminales.  Outside  the  pelvic  cavity,  are  the 
thigh  bones  divided  through  the  neck,  with  the  ligaments  and  their 
corresponding  vessels  and  muscles.  As  the  head  of  the  thigh  bone 
presents  a  spherical  form  only  internally  and  above,  so  each  transverse 


PLATE  XYII 


141 


section  which  passes  through  it  near  its  middle  includes  a  portion  of 
its  neck,  and  therefore  produces  externally  a  cut  surface  very  far  removed 
from  a  circle.  The  inner  contour  only  would  present  a  portion  of  a  circle, 
namely  at  the  point  of  insertion  of  the  ligamentum  teres.  The  component 
portion  of  the  joint  is  better  seen  higher  up. 

Fig.  4  is  taken  from  a  series   of  sections  on  the  body  of  an  old  man, 


Section  of  the  pelvis  of  an  old  man  at  the  level  of  the  great  sacro- sciatic  ligament. 

1,1.  Head  of  thigh  bone.     2.  Rectum.     3.  Apex  of  bladder.     4,4.  Femoral  vessels. 
5.  Lower  end  of  sacrum.     6,  6.  Gluteus  maximus. 

somewhat  higher  than  Plate  XVII,  and  is  therefore  useful  in  comparison 
with  it,  since  it  traverses  the  entire  length  of  the  sacro-sciatic  ligament. 

The  acetabula  are  divided  nearly  through  their  centre.  Nothing  more 
of  the  symphysis  pubis  is  to  be  seen,  as  in  consequence  of  the  greater 
inclination  of  the  pelvis  it  lies  considerably  deeper.  The  relation  of  the 
vasa  deferentia  to  the  femoral  vessels  is  well  shown.  Corresponding 
with  the  deeper  position  of  the  viscera  in  old  persons  already  mentioned, 
a  quantity  of  coils  of  small  intestine  are  here  shown,  whereas  on  Plate 
XVII  there  is  merely  a  small  flat  section  of  the  ileum. 


PLATE  XVIII 

IT  appears  to  me  desirable  to  introduce  here  a  frontal  section  of  the 
pelvis,  and  one  that  will  show  the  relations  of  the  hip-joint  to  the  best 
possible  advantage.  After  many  investigations,  I  became  convinced  that 
for  this  purpose  a  definite  position  of  the  bones  is  necessary,  as  when  the 
subject  lies  on  the  back  they  are  rolled  outwards,  and  the  head,  neck, 
and  shaft  do  not  lie  in  the  same  plane.  It  is  only  when  the  thigh  is 
rolled  considerably  inwards,  so  that  the  inner  borders  of  both  feet  touch 
throughout  their  entire  length,  that  they  do  so ;  I  made  the  section,  there- 
fore, with  the  feet  tied  together. 

The  section  passed  through  the  pelvis  and  hip-joint  in  such  a  manner 
as  to  render  the  two  sides  as  symmetrical  as  possible.  The  upper  portion 
of  the  shaft  of  the  right  femur  is  not  divided  quite  in  its  axis,  and  only  a 
portion  of  the  great  trochanter  is  clear,  while  the  lesser  trochanter  is 
covered  with  muscles.  The  head  and  neck  are  fairly  divided.  The 
section  passed  through  the  middle  of  the  acetabulum ;  through  the  whole 
length  of  the  ligamentum  teres  of  both  sides,  the  obturator  foramen 
and  the  ilium.  The  promontory  of  the  sacrum  and  the  tuberosities  of  the 
ischium  lie  in  the  posterior  half  of  the  body. 

The  preparation  is  viewed  from  the  front,  and  thus  the  right  side  of 
the  body  is  to  the  left  of  the  picture  and  the  converse.  It  represents 
the  lower  portion  of  the  abdominal  cavity,  bounded  above  by  the  three  flat 
abdominal  muscles,  and  more  externally  by  the  iliaco-psoae,  in  which  are  the 
anterior  crural  nerves.  Within  these  muscular  walls  are  the  intestines, 
extending  as  far  down  as  the  bladder,  the  anterior  portion  of  the  cavity 
of  which  is  opened.  The  sections  of  the  small  intestine,  which  above  is 


PLATE   XVIII  143 

jejunum  and  below  ileum,  as  can  be  readily  recognised  from  the  nature  of 
their  mucous  coats,  indicate  that  in  many  instances  they  have  been  met 
with  in  their  long  axis.  There  are  singularly  few  instances  in  which  this 
has  happened  in  the  preceding  sections,  and  it  therefore  follows  that  the 
coils  of  intestine  have  a  parallel  direction  with  the  long  axis  of  the  body. 

Of  the  individual  portions  of  the  intestine,  the  section  of  the  vermiform 
process  is  seen  at  the  upper  border  of  the  right  psoas  ;  and  on  the  left  of  the 
iliac  vein  the  transverse  section  of  the  rectum.  The  latter  was  especially 
studied  in  relation  to  its  course.  It  ascended  behind  Douglas's  pouch,  in 
the  left  half  of  the  body  near  the  middle  line  ;  curved  sharply  forwards  over 
the  left  psoas  muscle,  so  that  it  fell  in  the  plane  of  the  section ;  and  then 
passed  somewhat  forwards  towards  the  right  half  of  the  body  as  an 
arc  of  a  large  curve,  ultimately  becoming  continuous  with  the  descend- 
ing colon.  It  shows,  moreover,  a  deviation  from  the  usual  course, 
at  the  lower  portion,  as  figured  by  Pirogoff  (fasc.  iii  B,  tab.  xv,  fig.  1),  but 
does  not  completely  correspond  with  the  relations  shown  in  Plates  I  and  II; 
and  one  can  easily  convince  oneself  by  injecting  with  tallow  that,  in  individual 
cases,  and  those  not  very  rare,  the  $-curve  of  the  rectum  is  not  sharply 
marked  in  a  frontal  direction  with  regard  to  the  sacrum, — variations  which 
are  owing  to  the  inconstant  length  of  the  meso-rectum.  Should  this  be 
strong  and  reach  far  back,  the  position  of  the  rectum  is  freer,  and  more 
dependent  on  the  condition  of  the  neighbouring  organs.  Shortness  and 
tenseness  of  this  meso-rectum,  on  the  other  hand,  contribute  to  a  firm  and 
constant  position  of  the  intestine. 

The  effect  produced  by  the  distension  and  by  the  firmness  of  the  walls 
of  the  rectum  must  be  taken  into  consideration.  Great  distension  from 
faeces,  and  flaccidity  of  its  walls  especially,  permit  of  considerable  stretch- 
ing of  the  original  curves.  It  can  be  proved  by  investigation  and  clinical 
observations,  that  the  surgeon  can  straighten  the  curved  rectum  by  means 
of  instruments,  and  introduce  them  as  far  as  the  iliac  flexure.  Foreign 
bodies  introduced  from  the  anus,  and  firmly  impacted,  can  be  seized  with 
forceps  and  withdrawn. 

The  bladder  contained  a  little  urine,  and  was  firmly  contracted :  it  is 
separated  from  the  section  of  the  levator  ani  by  a  little  fat ;  on  both  sides 


144  PLATE   XVIII 

of  the  levator  ani  lie  the  sections  of  the  obturator  internus,  bounded  below 
by  the  obturator  membrane,  and  laterally  by  the  pelvic  bones.  If  the  space 
between  the  intestines  and  the  pelvis  be  followed  upwards  on  both  sides 
from  the  bladder,  beneath  the  peritoneum,  we  meet  with  two  whitish  oval 
sections,  which  represent  the  lateral  ligaments  of  the  bladder.  They  lie 
thus  far  removed  from  the  bladder,  because  it  was  small  and  contracted  ;  a 
distended  bladder  would  carry  them  upon  its  upper  surface,  and  at  the 
same  time  occupy  the  entire  space  of  the  inferior  aperture  of  the  pelvis,  as 
several  of  Pirogoff's  plates  show.  Farther  outwards,  and  in  the  same  space, 
between  the  peritoneum  and  the  pelvis,  is  the  vas  deferens,  and  above  it 
the  obturator  vein  and  nerve  and  a  small  artery.  The  main  trunk  of  the 
artery  passes  through  the  obturator  foramen. 

Finally,  we  arrive  at  the  external  iliac  artery  and  vein ;  both  vessels 
lie  on  the  inner  wall  of  the  psoas,  as  the  preceding  sections  show,  not  side 
by  side,  but  behind  each  other ;  hence  the  artery  lies  over  the  vein,  and  not  to 
its  inner  side  as  appears  by  this  frontal  section. 

The  relations  of  the  hip-joint,  which  have  been  already  briefly  alluded  to, 
afford  many  points  for  examination.  It  has  been  already  mentioned  that 
the  section  has  traversed  the  entire  length  of  the  ligamentum  teres  of  both 
sides.  It  is  evident  that  this  ligament  limits  extreme  adduction,  and  by 
simultaneous  stretching,  assists  in  maintaining  the  firm  position  of  the  pelvis 
and  trunk.  As  the  section  passed  through  the  acetabular  notch  the  course 
of  the  articular  artery  is  exposed. 

The  articular  cartilage,  ligamentous  apparatus,  and  the  extent  of  the 
cavity  of  the  joint  are  well  seen  in  the  plate. 

The  architecture  of  the  upper  portion  of  the  thigh  bone  is  well  worthy 
of  study,  as  much  so  for  its  general  disposition  as  for  its  structure.  Meyer 
has  the  merit  of  having  first  called  attention  to  the  arrangement  of  the 
cancellous  tissue,  especially  in  the  neck  of  the  bone,  which  essentially 
increases  its  weight-bearing  power.  The  individual  laminae  and  interlace- 
ments of  bone  arrange  themselves  in  rows,  which  are  detached  from  the 
borders  of  the  compact  tissue,  and  cross  each  other  in  the  middle  line.  In 
the  section  of  the  left  thigh  bone  especially  these  indications  of  its  structure 
are  shown. 


PLATE    XVIII  145 

The  articular  cavities  themselves  appear  merely  as  chinks.  Their 
extent  downwards  explains  to  what  limit  intracapsular  fracture  of  the 
neck  of  the  thigh  bone  may  reach,  and  where  the  region  of  extra-capsular 
fracture  commences.  Since  intra-capsular  fractures  isolate  the  upper 
fragment,  and  leave  it  connected  by  the  ligamentum  teres  and  the  aceta- 
bular  vessels,  it  is  evident  that,  apart  from  the  difficulty  of  accurate 
adaptation  and  retention  of  the  parts,  union  is  of  very  rare  occurrence, 
on  account  of  conditions  unfavourable  for  its  nutrition. 

An  increase  of  effusion  into  the  joint,  as  may  happen  in  inflammation, 
will  not  separate  the  surfaces  of  the  acetabulum  and  head  of  the  thigh 
bone.  The  powerful  ilio-femoral  ligament,  in  consequence  of  its  torsion 
in  complete  extension,  presses  the  joint-surfaces  firmly  against  each  other. 
On  the  other  hand,  in  flexing  the  joint,  a  corresponding  separation  of  the 
two  surfaces  will  occur  from  increased  effusion  within  it ;  and,  as  inves- 
tigations show,  this  may  be  somewhat  considerable.  If  fluid  be  injected 
through  the  acetabulum  into  the  joint-cavity,  after  the  example  of 
Bonnet,  the  articulation  takes  successively  the  positions  which  afford  the 
greatest  amount  of  space ;  but  which  ultimately  place  the  ilio-femoral 
ligament  in  the  condition  of  greatest  relaxation.  The  femur  is  raised 
and  somewhat  rolled  outwards.  If  the  joint  be  frozen,  sections  can  be 
made  of  it,  and  the  relations  of  the  articular  surfaces  to  each  other  ren- 
dered clear.  The  accompanying  woodcut  represents  such  a  preparation, 
made  from  the  body  of  a  normal  young  female. 

In  order  to  render  the  femur  more  easily  movable,  the  upper 
layer  of  muscles  was  removed  and  the  bone  itself  sawn  through  the 
middle. 

On  injecting  the  joint  with  tallow,  and  applying  as  great  a  pressure 
as  possible,  the  femur  was  raised  and  rolled  outwards.  In  this  position 
it  was  frozen  and  sawn  as  shown  in  the  woodcut ;  the  section  passing  not 
quite  through  the  middle  of  the  head,  but  slightly  in  "front,  and  including 
the  trochanter  minor  in  its  course.  The  mass  of  tallow,  which  is  here 
represented  by  the  dark  shading,  was  about  one  fifth  of  an  inch  thick,  and 
a  little  farther  down  in  the  articulation  somewhat  thicker ;  and  surrounded 
the  head  of  the  bone  like  a  cap,  extending  outwards  to  the  attachment  of 

19 


146 


PLATE    XVIII 


the  synovial  membrane,  which  was  driven  forwards  in  the  form  of  a  bladder 

FIG.  1.  on  its  posterior  wall.    We 

should  expect  to  find,  in 
diseases  of  the  hip -joint 
which  exhibit  similar  posi- 
tions of  the  articulation, 
an  actual  lengthening  of 
the  thigh,  supposing  that 
a  like  quantity  of  fluid 
exists  in  the  joint  cavity. 
To  prove  this  by  measure- 
ment is  impracticable. 
Were  it  possible  to  mea- 
sure it  accurately  to  a 
quarter  of  an  inch,  which 
from  the  simultaneous 
displacement  of  the  pel- 
vis can  hardly  be  ex- 
pected, the  flexion  of 
the  thigh,  associated  with 
this  condition,  renders 
such  measurement  im- 
practicable. 

The  relations  of  the 
corpora  cavernosa  and 
urethra  next  demand  at- 
tention. It  will  be  seen 
that  the  section  passes 
in  front  of  the  prostate, 

dividing  the  corpora  cavernosa  penis  near  their  origins,  and  the  urethra  at 

the  bulb. 

The  corpus  cavernosum,  arteries,  and  muscles  of  the  corpus  cavernosum 

are  well  shown.     Upon  it  is  expanded  a  portion  of  the  deep  perineal  muscle 

with  a  number  of  large  veins. 


Frontal  section  of  the  hip-joint  injected  with  tallow  and 
frozen.  J. 

1.  Head  of  femur.  2.  Tendon  of  rectus.  3.  Obturator 
externus.  4.  Pectineus.  5.  Tendon  of  ilio-psoas.  6. 
Glutens  minimus. 


PLATE    XVIII 

FIG.  2. 


147 


Frontal  section  of  the  male  pelvis  through  the  membranous  portion  of  the  urethra.     4- 

1.  Prostate.  2.  Wall  of  bladder.  3.  Caput  gallinaginis.  4.  Deep  transversus  perinei  muscle. 
5.  Bulb.  6.  Ascending  ramus  of  the  ischium.  7.  Obturator  membrane.  8.  Obturator  externus. 
9.  Obturator  internus.  10.  Adductor  magnus. 


148  PLATE    XVIII 

As  it  appeared  to  me  desirable  to  have  a  section  showing  these  struc- 
tures rather  farther  back,  I  made  one  on  the  body  of  a  normal  well-built 
man,  at  such  a  depth  as  to  pass  through  the  prostatic  portion  of  the  urethra. 
The  preceding  woodcut  represents  the  plate  on  a  smaller  scale.  The  head 
of  the  left  femur  is  seen  only  as  a  small  segment,  and  not  in  connection 
with  the  rest  of  the  bone. 

The  body  of  the  ischium  shows  a  large  surface  in  section,  corresponding 
with  its  more  extensive  development  behind  the  acetabulum.  The  obturator 
membrane,  ascending  ramus  of  ischium,  and  the  obturator  externus  and 
internus,  still  show  some  resemblance  to  the  corresponding  portions  on 
Plate  XVIII,  and  so  also  do  the  corpora  cavernosa.  We  have,  moreover, 
in  the  section,  in  place  of  the  apex  of  the  bladder,  its  posterior  wall,  and 
the  posterior  half  of  the  prostate,  with  the  caput  gallinaginis. 

The  membranous  portion  of  the  urethra  and  the  prostate  are  opened.  On 
both  sides  of  it  are  the  deep  transverse  perineal  muscles,  the  fibres  of  which 
are  expanded  towards  the  middle  line.  Above  is  seen  the  anterior  mass  of 
the  levator  ani.  Around  it  is  a  layer  of  fascia,  the  upper  portion  of  which 
is  continuous  with  the  pelvic  and  the  lower  with  the  perineal  fasciae. 
Both  fasciae  meet  at  the  inner  border  of  the  levator  ani  muscle,  and  help  to 
support  the  prostate.  The  upper  lamina  of  the  perineal  fascia  and  the 
lower  surface  of  the  transversus  perinei  pass  forwards. 

The  plate,  which  must  not  be  regarded  as  diagrammatic,  agrees  in  all  its 
essential  particulars  tolerably  accurately  with  Henle  (*  Eingeweidelehre,' 
p.  504,  fig.  392),  which  should  be  compared  with  it. 


s 


1=1 

•o 


PLATE    XIX 

IN  order  to  demonstrate  the  shape  of  the  cavity  of  the  knee-joint  and 
the  extent  of  its  capsule  correctly,  I  injected  water  into  the  articulation 
with  a  Pravaz's  needle  under  great  pressure,  and,  having  slightly  flexed 
the  joint,  froze  it.  The  limb  was  taken  from  a  normal  body  (young 
female).  The  section  passed  tolerably  nearly  through  the  middle,  and 
divided  the  extremity  into  two  nearly  equal  halves,  of  which  the  right 
one  was  used  for  the  plate,  after  the  removal  of  the  frozen  water. 

All  the  joints,  not  the  hip  and  shoulder  only,  are  subject  to  atmo- 
spheric pressure ;  and,  on  account  of  the  small  quantity  of  synovia  which 
they  contain,  can  retain  their  normal  position  and  not  show  free  cavities,  as 
one  finds  on  opening  a  joint  in  a  soft  preparation.  Accordingly  the  synovial 
cavity  appears  in  the  section  of  a  normal  joint  as  a  narrow  crevice:,  which 
in  the  following  section  of  a  normal  uninjected  knee-joint  is  represented 
by  a  single  black  line. 

If  this  joint  be  compared  with  the  injected  specimen,  as  represented  in 
Plate  XIX,  one  can  understand  the  meaning  of  the  black  line  which 
indicates  the  joint  cavity.  Further,  the  position  of  the  patella  is  seen  in 
normal  and  abnormal  joints.  Whilst  in  the  normal  condition  of  the  joint 
the  patella  touches  the  femur  with  a  small  portion  of  its  cartilaginous 
surface  like  a  tangent,  in  the  case  of  the  distended  synovial  membrane  it  is 
completely  lifted  off  it.  The  patella  floats,  supported  by  the  fluid  as  a 
board  on  water,  and  must  therefore  yield  under  pressure  of  the  finger 
until  it  reaches  the  femur,  which  lies  behind  it. 

The  capacity  of  the  joint-cavity  is  well  shown,  whilst  in  the  woodcut 
the  synovial  membrane  of  the  extensor  muscles  appears  as  separated  from 
it,  since  the  wide  aperture  of  communication  which  unites  it  with  the 
bulging  out  of  the  capsule  is  not  opened  by  the  section  ;  and  on  the  injected 


150 


PLATE  XIX 


FlQ.   1. 


joint  represented  in  Plate  XIX  no  such  separation  is  to  be  seen. 
The  fluid  injected  has  penetrated  into  all  the  portions  and  hollows  of  the 

joint,  and  has  raised  up  the 
posterior  wall  of  the  capsule, 
so  that  the  posterior  portion  of 
the  condyle  of  the  femur  is 
brought  into  view. 

The  ligamentum  mucosum 
of  the  patella  and  the  ante- 
rior crucial  ligament  lie  in  the 
plane  of  section. 

It  is  well  known  that  Bon- 
net was  the  first  to  apply  the 
method  of  injection  to  the  in- 
vestigation of  joints,  and  to 
prove  thereby  what  position 
of  the  joint  corresponded  with 
the  greatest  distension  of  the 
synovial  cavity.  It  appeared 
in  all  joints  that  it  was  the  po- 
sition of  flexion  that  allowed 
of  the  greatest  amount  of  fluid 
entering  the  articular  cavity; 
and  that,  with  strong  pressure 
of  injection,  all  joints,  no  matter 
what  position  they  may  have 

had  beforehand,  acquire  the  position  of  flexion  and  maintain  it  so  long 
as  the  pressure  is  continued.  It  is  natural  to  suppose  also  that  in 
diseases  of  the  joint,  associated  with  effusion  into  the  synovial  cavity, 
the  position  of  flexion  which  the  patients  involuntarily  affect  is  brought 
about  by  the  direct  pressure  of  the  fluid. 

But  against  such  a  supposition  the  following  points  may  be  adduced, 
as  can  be  well  explained  after  consideration  of  this  plate. 

The  capacity  of  the  joint-cavity  also  depends  on  the  possibility  of  the 


Longitudinal  section  of  the  frozen  knee-joint  of  a 
full-grown  man.    £.  4 

1.  Femur.  2.  Tibia.  3.  Patella.  4.  Posterior 
crucial  ligament  divided.  5.  Bursa  mucosa.  6. 
Quadriceps  extensor.  7.  Ligamentum  patellae.  8. 
Semi-membranosus.  9.  Gastrocnemius. 


PLATE   XIX  151 

separation  of  the  patella  which  is  developed  in  the  extensor  tendon  from 
the  surfaces  of  the  condyles.  This  is,  however,  the  case  when  the 
extensor  tendon  is  relaxed,  as  in  extension,  or  in  only  slight  flexion  of 
the  joint ;  in  greater  flexion  the  patella  must  be  pressed  against  the  con- 
dyles, by  the  tension  of  the  quadriceps,  thus  causing  a  diminution  of  the 
capsular  cavity.  It  will  therefore  be  expected  that  in  consequence  of  the 
extension  of  the  synovial  space  upwards  beneath  the  extensor  tendon,  a 
considerable  quantity  of  fluid  may  be  injected,  and  that  a  greater  degree 
of  flexion  must  directly  diminish  the  amount.  I  therefore  considered  it 
necessary  to  undertake  a  repetition  of  Bonnet's  researches  with  the  greatest 
possible  care,  and  that  on  entire  bodies.  The  method  I  used  was  the 
following  : 

The  subject  was  fresh  and  normal,  and,  after  violently  breaking  down 
the  rigor  mortis  of  the  lower  extremities,  was  laid  on  its  back  on  a  hori- 
zontal table.  The  thigh  hung  down  over  the  free  edge,  and  during  the 
investigation  was  fixed  by  means  of  a  support  under  the  heel  by  an 
assistant  in  the  necessary  position.  A  screw  was  driven  into  the  upper 
third  of  the  tibia,  to  the  free  extremity  of  which  a  flat  piece  of  wood  was 
fastened ;  which  served  to  fix  a  dial  plate,  provided  with  a  graduated  semi- 
circle ;  and  it  was  so  arranged  that  a  plumbline  fastened  to  the  centre  of 
the  circle  stood  at  zero  in  complete  extension  of  the  bone,  and  the  amount 
of  flexion  could  be  immediately  read  off.  No  regard  was  taken  of  the 
rotation  of  the  thigh  during  flexion.  In  order  to  prevent  diffusion  through 
the  capsule,  the  fluid  used  for  injection  was  a  solution  of  common  salt, 
contained  in  a  graduated  tube  about  sixty  inches  in  length,  to  the 
inferior  end  of  which  was  fastened  a  short  piece  of  tubing  of  india 
rubber,  carrying  a  strong  Pravaz's  needle.  The  tube  was  fixed  in  an 
oblique  position  by  means  of  a  movable  support,  so  that  the  vertical  line, 
indicating  the  difference  in  height  of  the  point  of  introduction  of  the 
needle  and  of  the  level  of  the  fluid,  always  remained  the  same ;  by  which 
means  the  pressure  indicated  by  the  constant  height  of  the  support  was 
maintained.  The  apparatus  thus  formed  a  right-angled  triangle  whose 
hypothenuse  was  represented  by  the  obliquely  directed  tube,  the  perpen- 
dicular by  a  portion  of  the  support,  and  the  base  by  a  horizontal  line  running 


152      .  PLATE   XIX 

parallel  to  the  table  and  extending  from  the  point  of  introduction  of  the 
needle  to  the  support.  The  point  of  introduction  of  the  needle  being  as 
near  as  possible  in  the  axis  of  rotation,  it  remained  almost  unaltered  in 
flexion  of  the  knee-joint ;  consequently  it  was  possible  from  the  changing 
level  of  the  water  in  the  tube,  to  read  off  the  diminution  or  the  increase 
of  the  fluid  in  cubic  centimetres.  Of  course,  the  support  had  to  be  con- 
stantly placed  under  the  meniscus  of  the  fluid,  whilst  the  zero  point 
of  the  tube  was  kept  in  an  unaltered  position  relatively  with  the  point 
of  introduction  of  the  needle.  Thus,  whilst  the  side  of  the  triangle  indi- 
cating the  pressure  was  constant,  the  length  of  the  hypothenuse  and  that 
of  the  other  side  varied,  becoming  larger  on  diminution  of  the  volume  of 
the  synovial  space,  and  smaller  in  the  contrary  condition. 

By  means  of  this  method  of  investigation  it  was  possible  to  determine 
the  following  points  which  Bonnet's  proceeding  could  not  afford.  We 
could  immediately  ascertain  the  dependence  of  the  capacity  of  the  synovial 
cavity  on  the  angle  at  which  the  bone  was  placed,  since  the  pressure  of 
the  fluid  in  the  walls  of  the  capsule  always  remained  one  and  the  same, 
and  these  in  the  intact  condition  of  the  body  and  extremity  presented 
their  original  relations  to  skin,  fat,  muscle,  &c.  Thus  the  grade  of 
flexion,  in  which  the  synovial  cavity  reached  the  maximum  of  its  capa- 
city (described  by  Bonnet  as  the  mid-position  between  flexion  and  exten- 
sion), could  be  accurately  recorded.  Finally,  the  volume  of  the  synovial 
space  during  the  different  positions  of  the  bone  could  be  measured  by  cubic 
centimetres.  The  following  figures,  which  indicate  each  angle  of  flexion, 
will  be  easily  understood  after  the  preceding  description.  0°  corresponds 
with  complete  extension,  10°  would  indicate  that  the  thigh  made  an  angle 
of  170°  with  the  leg,  &c. 

The  figures  referring  to  the  volume  give  the  quantity  of  fluid  in  the 
capsule  in  each  case,  in  cubic  centimetres ;  those  referring  to  pressure,  in 
centimetres. 

Experiment  1. — Body  of  a  man,  aet.  50;  tolerably  recent.  Muscular 
development  and  nourishment  good.  The  rigor  mortis  of  the  limb  forcibly 
broken  down.  Pressure  19  centimetres. 


PLATE   XIX  153 

Angle          .     0°    10°    20°   30°   40°    50°    60°   70°    80°   90°  100° 

Volume       .  312  328  332  331  330  326  316  303  283  265  255  c.c. 

Experiment  2. — Body  quite  recent.  No  rigor  mortis.  Pressure  23 
centimetres. 

Angle          .     0°    10°  20°    30°   40°    50°    60°    70°   80°  90°  100°  110° 

Volume       .  114  128  137  141  141  140  135  125  112  99     76      75  c.c. 

Experiment  3. — The  opposite  knee  of  the  same  body.  Pressure  34  cen- 
timetres. 

Angle          .    0°  10°  20°    30°   40°    50°    60°  70°  80°  90°    100°  110° 

Volume       .  83  95  104  111  110  109  107   93    91    83      66      54  c.c. 

Experiment  4. — Body  of  a  man,  set.  50;  eight  days  dead,  poorly 
nourished.  Rigor  mortis  forcibly  broken  down.  Pressure  14  centimetres. 

Angle          .        0°      10°     20°     30°  40°    50°   60°     70°   80°  90° 

Volume       .    143J  149J  154J  146i  139  136  118    102    88    78  c.c. 

Experiment  5. — Body  of  a  muscular  man,  set.  36 ;  rigor  mortis  broken 
down. 

Angle          .    0°  10°  20°  30°   40°  50°  60°  70°  80°  90°  100° 

Volume       .    79  90  98  104  101    98    82    91    67    50    32  c.c. 

Experiment  6. — Well-nourished  male,  set.  30.  Knee  very  rigid.  Pressure 
52  centimetres. 

Angle  '        .       0°      10°    20°     30°     40°    50°    60°    70°    80° 

Volume       .  108J  H2£  125  125J  124£  115    105    101     95  c.c. 

The  results  which  follow  from  these  researches  I  may  sum  up  in  the 
following  propositions  : 

1.  That  the  knee-joint,  in  equal  stages  of  flexion  in  different  individuals, 
shows  a  very  great  difference  in  the  capacity  of  its  synovial  membrane. 

The  difference  of  the  pressure  need  not  be  taken  into  account,  as, 
indeed,  at  the  lowest  pressure  the  volume  of  fluid  in  the  joint  was  a 
maximum.  It  is  the  connection  of  the  joint  cavity  with  neighbouring 
synovial  sacs  which  causes  this  phenomenon. 

*  I  have  left  the  figures  referring  to  the  volumes  in  cubic  centimetres  and  the  pressures  in 
centimetres,  since,  for  any  practical  purpose  for  which  this  table  may  be  available,  the  following 
equations  will  facilitate  their  reduction  to  English  measure : 

1  centimetre  =  -3937  inch  =  -4  inch  nearly. 

1  cubic  centimetre  =  "061  cubic  inch  =  '0352  fl.  oz.  nearly— TR. 

20 


154  PLATE   XIX 

2.  That   the    capacity  of  the  sync-vial    cavity    reaches    its    maximum 
in  a  definite  degree  of  flexion,  and  that  the  angle  at  which  this  happens 
is  25°. 

We  learn  from  this  that  the  statement  of  Bonnet,  that  the  maximum 
capacity  happens  in  the  position  of  semi-flexion  is  incorrect,  as  we  see  that 
the  position  in  which  this  condition  exists  is  rather  at  the  commencement 
of  flexion . 

But  a  second  and  not  less  interesting  relation  is  evident  from  the 
preceding  experiments.  It  is  that  the  increase  of  capacity  is  the  greatest 
from  extreme  extension  to  10°  of  flexion,  less  from  10° — 20°,  and  still  less 
from  20° — 30°.  An  important  practical  fact  follows  from  this,  that  a  slight 
degree  of  flexion,  such  as  10°,  determines  the  relatively  greatest  increase  of 
capacity  of  the  capsule. 

If  the  joint  be  in  the  position  attained,  when  filled  with  fluid  to  its 
greatest  extent,  it  may  be  forcibly  extended  without  fear  of  rupture  of  the 
capsule ;  and  here,  again,  my  results  differ  from  those  of  Bonnet. 

3.  The   minimum   of   the   capacity    of  the    synovial   cavity    coincides 
with  the  maximum  of  flexion.     Hence,  the  idea  expressed  by  Bonnet  on 
the  method  of  treating   penetrating  wounds  of  joints   is  disproved — that 
the   extension    is    the    position    in    which    the    capacity    of    the    capsule 
diminishes.     Although    in    extension,    as    sections    of    frozen  tnee-joints 
show,    the    joint    surfaces    are   closely    approximated    by   means    of  the 
tensely   stretched   lateral   ligaments,   the    spaciousness    of  the  capsule   in 
this  position  is,  nevertheless,  very  considerable ;    and  it  is  larger  in  serai- 
flexion  than  in  complete.     If  the  knee  be  forcibly  flexed,  and  if  the  joint 
be   now  entirely    filled  with   fluid,   there   ensues   a   degree    of  flexion  by 
which  the   wall   of  the    capsule   is  ruptured   and   the   fluid   escapes   into 
the  cellular  tissue. 

Moreover  the  clinical  relations  throw  considerable  doubt  upon  the 
correctness  of  Bonnet's  theory  of  the  mechanism  of  the  knee-joint.  In  such 
cases  as  acute  arthro-synovitis,  the  ligamentous  structures  specially  suffer, 
and  disease  is  distinguished  by  copious  effusion  into  the  articulation.  We 
frequently  find  complete  extension  of  the  knee-joint  throughout  the 
course  of  the  disease — an  observation  which  I  have  repeatedly  made,  and 


PLATE   XIX  155 

which  is  corroborated  by  Volkmann  ('  Krankheiten  der  Bewegungsorgane,' 
1865,  p.  195).  Again,  effusion  of  blood  into  the  joint  in  an  extended 
position  of  the  extremity  exhibits  symptoms  compatible  with  this. 

Figure  2. — This  section  of  a  normal  right  foot  is  from  the  same  body. 
The  section  runs  near  the  inner  border  of  the  foot,  and  divides  in  succes- 
sion the  tibia,  astragalus,  scaphoid,  internal  cuneiform  and  first  metatarsal 
bones,  and  the  first  phalanx  of  the  great  toe.  The  saw  has  missed  the 
second  phalanx,  as  the  toe  was  somewhat  bent  outwards. 

The  section  passes  nearer  the  inner  border  of  the  foot  than  that  repre- 
sented by  Weber  ('  Gehwerkzeuge,'  tab.  xi),  Volz  ('Beitrag  zur  Chirurg  Anat.,' 
tab.  x),  Henle  (*  Gelenke,'  figs.  136,  137).  It  was  only  just  possible  to 
avoid  the  cuboid  and  third  cuneiform  bones  which  project  inwards  so  much 
that  they  would  have  been  divided  by  any  section  passing  further  outwards, 
and  made  the  relations  of  the  plate  more  complicated.  The  bones  of  the 
foot  are  not  placed  so  that  they  simply  form  an  arch  from  before  back- 
wards, but  there  is  also  one  in  a  transverse  direction. 

It  can  be  easily  proved  by  measurement,  that  from  the  pressure  exerted 
by  the  weight  of  the  body,  in  the  upright  position,  the  curves  of  the 
skeleton  of  the  foot  are  flattened  in  both  directions,  and  that  the  foot  is  not 
only  lengthened  but  broadened. 

It  is  clearly  seen  from  the  plate,  that  the  astragalus  which  has 
been  divided  exactly  at  the  attachment  of  the  interosseous  ligament, 
is  set  as  the  keystone  of  the  arch.  It  is  wedged  in  between  the  sca- 
phoid and  os  calcis,  is  pressed  against  them  both,  and  thus  prevents  their 
approach. 

The  ligaments  correspond  with  the  structure  of  the  arch,  which  the 
several  bones  of  the  foot  form.  They  are  proportionally  weaker  on  the 
convex  dorsum,  where  they  hold  the  separate  bones  in  position  during 
pressure  on  the  arch;  and  extraordinarily  strong  on  the  plantar  aspect, 
where  their  function  is  to  act  as  a  tie  beam,  and  prevent  separation  of 
the  bones  :  and  it  is  not  the  form  of  the  bones  alone  that  renders  the  arch 
secure,  since  they  would  fall  apart  were  it  not  for  the  immensely  strong 
ligamentous  arrangement  of  the  sole  of  the  foot,  strengthened  by  the 
plantar  fascia. 


156  PLATE   XIX 

There  is  no  necessity  for  mentioning  the  individual  parts.  The  accurate 
drawing  itself  sufficiently  explains  the  soft  parts.  Some  notice  must  be 
taken  of  the  pad  of  fat  which  is  so  largely  developed  at  the  point  of  greatest 
pressure  on  the  sole,  and  which  diminishes  and  distributes  as  much  as  possible 
this  pressure  over  different  points.  Over  the  heel  and  in  the  region  of  the 
ball  of  the  great  toe  it  is  half  an  inch  thick ;  thus  affording  a  soft  support, 
which  partially  equalises  the  irregularities  of  the  ground. 


Fig.I. 


Tab.  XX. 


PLATE    XX 

THESE  two  sections  of  the  thigh  were  taken  from  the  same  individual 
as  Plates  I  A  and  I  B.  The  sections  were  so  directed  that  the  first 
(tab.  xx,  fig.  1)  passed  immediately  below  Poupart's  ligament  and 
parallel  with  it,  but  obliquely  with  the  direction  of  the  thigh  itself;  it  is 
consequently  a  section  of  Scarpa's  triangle,  and  should  be  compared  with 
that  given  by  Legendre  ('  Anat.  Homolograph,'  PL  XXIII),  and  by 
Voltz  ('  Chirurg.  Anat.  der  Extrem.,'  Tafl.  vi,  fig.  3).  The  second  section 
(tab.  xx,  fig.  2)  was  not  parallel  with  the  first,  but  at  right  angles  to  the 
axis  of  the  thigh  near  the  perineum,  so  that  the  two  sections  would 
include  a  wedge  taken  out  of  the  thigh,  with  the  base  external  and  the  apex 
internal. 

The  following  sections  ran  parallel  to  each  other,  and  they  form  a 
segment  of  about  1'6  inches  thick.  They  are  from  a  very  muscular  thigh, 
and  form  a  series.  The  other  sections,  from  below  the  knee  to  the  foot, 
are  taken  from  another,  though  equally  normal,  male  subject,  and  show  the 
same  relations. 

The  upper  surfaces  furnish  the  plates ;  and  these,  from  the  symmetrical 
structure  of  the  extremities,  will  serve  equally  well  for  either  limb,  although 
they  happen  to  be  taken  from  the  left ;  by  being  reversed  they  will  correspond 
with  the  right,  so  that  the  under  surface  may  be  regarded  as  the  stump  of 
an  amputation. 

With  regard  to  the  bones,  we  first  notice,  in  tab.xx,  fig.  1,  the  absolutely 
circular  section  of  the  head  of  the  femur  completely  surrounded  by  a  thin 
layer  of  cartilage,  behind  which  is  seen  the  cavity  of  the  joint  as  a  dark 
circle.  It  is  enclosed  by  a  portion  of  the  acetabulum,  which  is  joined  by 
the  divided  part  of  the  ischium,  or  rather  by  its  upper  ramus.  The  section 


158  PLATE  XX 

has  then  passed  through  the  obturator  foramen,  obliquely  outwards  through 
the  ascending  ramus  of  the  pubis  and  corpus  cavernosum  penis,  the  obturator 
membrane,  and  the  sacro-sciatic  ligament. 

Above  the  capsule  of  the  hip-joint  through  the  divided  synovia]  mem- 
brane is  observed  the  psoas  muscle  and  the  portion  of  the  iliacus  associated 
with  it.  Below  the  outer  extremity  of  this  muscle  is  the  section  of  the 
tendon  of  the  rectus  femoris.  The  second  head  of  this  muscle  is  incor- 
porated with  the  ligamentous  structures  at  the  brim  of  the  acetabulum, 
and  could  not  be  shown  separately  in  the  plate. 

Above  the  ilio-psoas,  is  seen  the  fascia  over  the  last  dorsal  nerve 
running  down  over  the  vessels  to  unite  with  the  fascia  of  the  pectineus, 
and  attaching  itself  to  the  capsule  of  the  hip -joint.  We  have  here  already 
the  commencement  of  the  sheath  of  the  femoral  vessels,  and  observe  how  it 
forms  a  prismatic  space,  the  outer  wall  of  which  bears  towards  the  sar- 
torius.  The  superior  boundary  of  this  space  would  be  indicated  by 
a  single  lamina,  as  is  shown  in  the  preparation.  External  to  the  sar- 
torius  is  the  origin  of  the  tensor  vaginae  femoris  attached  to  its  tendinous 
sheath,  and  between  them  the  external  cutaneous  nerve.  Next,  we  observe 
the  gluteus  medius  muscle  with  its  strong  tendinous  fascia  from  which  a 
portion  of  its  fibres  arise.  The  oblique  section  of  its  muscular  bundles 
is  not  quite  clearly  rendered  in  the  plate — a  remark  which  also  applies  to 
the  gluteus  minimus,  which  is  more  internal.  To  the  latter  is  attached 
the  tendon  of  the  pyriformis,  and  of  the  gemellus  superior  and  obtu- 
rator internus,  which  is  seen  in  its  angular  course  with  its  large  subjacent 
bursa. 

The  above-mentioned  series  of  muscles  forms  the  superior  limit 
of  the  space  occupied  by  the  vessels  and  nerves,  as  the  gluteus 
maximus  does  the  inferior.  The  great  sciatic  nerve  is  here  seen.  The 
fascia  which  comes  from  the  gluteus  medius,  to  cover  the  gluteus 
maximus,  is  considerably  thinner  on  the  latter  muscle,  passes  over  this 
median  ridge  to  be  partly  inserted  into  the  great  sacro-sciatic  ligament, 
and  partly  into  the  fascia  of  the  obturator  internus. 

Of  the  adductor  group  are  seen  the  sections  of  the  pectineus,  the  adductor 
longus,  and  the  adductor  brevis.  The  adductor  magnus  is  not  seen ;  and  the 


PLATE   XX  159 

gracilis  is  divided  in  its  tendinous  origin.  The  acetabular  artery,  which  in 
this  case  comes  from  the  internal  circumflex,  lies  close  on  the  hip-joint. 
Care  has  been  taken  to  represent  the  direction  of  the  fibres  of  the 
muscles,  and  also  the  masses  of  the  several  bundles  of  fibres  as  accu- 
rately as  possible,  the  coarse  fibres  of  the  gluteus  maximus  being  parti- 
cularly noticeable.  It  is  true  that  from  this  plate  hardly  sufficient  can  be 
gathered  to  form  a  correct  idea  of  the  formation  of  the  crural  ring,  and  the 
anatomical  relations  of  crural  hernia ;  but  we  shall  have  to  rest  contented 
with  having  obtained  the  idea  of  the  size  of  the  individual  portions  and 
the  position  of  their  layers  with  regard  to  each  other  in  their  natural 
relations,  and  I  do  not  think  that  we  should  have  gained  more  if  the 
section  had  been  taken  farther  up.  Linhart  has  already  correctly  remarked, 
that  for  the  representation  of  the  relations  of  crural  hernia  single  sections 
are  not  sufficient. 

Plate  XX,  fig.  2,  is  a  section  of  the  thigh  at  right  angles  to  its  axis 
immediately  below  the  trochanter  minor.  The  lower  portion  of  the  iliacus 
muscle  is  still  seen  on  the  inner  surface  of  the  thigh ;  close  to  it  and 
internally  the  pectineus ;  and  externally  the  crureus.  The  femoral  artery 
has  already  given  off  the  profunda,  which  is  separated  from  the  main  trunk 
by  a  lamina  of  fascia. 

The  three  adductors  lie  over  one  another  on  the  inner  side ;  and  above 
and  beneath  the  adductor  brevis  are  the  two  branches  of  the  obturator  nerve, 
with  it  the  branches  of  the  internal  circumflex  artery.  More  internally  is  the 
gracilis,  which  is  now  fleshy. 

The  sartorius  is  drawn  more  over  to  the  middle,  and  is  on  the  point 
of  overlapping,  like  a  muscular  roof,  the  femoral  artery,  which  vessel  has 
acquired  a  more  superficial  position  with  respect  to  its  accompanying 
vein. 

The  rectus  femoris  with  its  internal  tendinous  raphe,  lies  on  the  crureus 
and  vastus  externus,  and  near  it  the  tensor  vaginaa  femoris,  which  is 
enclosed  by  the  fascia  common  to  it  and  to  the  tendon  of  the  gluteus 
maximus. 

The  strong  lamina  of  fascia  which  passes  beneath  from  the  gluteus 
maximus,  and  turns  inwards  between  the  vastus  externus  and  rectus 


160  PLATE   XX 

femoris,  is  worthy  of  notice.  The  tendon  of  attachment  of  the  gluteus 
maximus  to  the  bone  is  not  yet  seen,  but  its  insertion  into  the  fascia  lata 
only,  which  is  especially  developed  at  the  external  surface  of  the  thigh. 
Covered  over,  but  separated  from  it  by  a  thin  lamina  of  fascia,  is  the 
common  head  of  the  biceps  and  semi-tendinosus,  and  above  that  the  strong 
tendon  of  the  semi-membranosus.  Between  it  and  the  adductor  magnus  is 
the  great  sciatic  nerve,  and  a  large  inosculating  branch  of  the  ischiatic  artery, 
with  the  first  perforating  and  the  profunda. 

The  segment,  the  upper  surface  of  which  is  here  represented,  was  about 
two  inches  thick.  If  the  sections  of  the  arteries  in  both  plates  be  com- 
pared, it  will  be  seen  that  the  femoral  artery  changes  its  position  with  regard 
to  the  bone,  and  to  its  accompanying  vein,  in  its  course  downwards.  At  the 
level  of  the  horizontal  ramus  of  the  pubes  it  lies  so  near  the  bone,  that 
the  possibility  of  its  compression  against  it  was  obvious ;  in  fig.  1  the 
distance  of  the  artery  from  the  head  of  the  bone  is  so  inconsiderable  that 
pressure  could  be  readily  exerted  on  the  vessel ;  whilst  in  fig.  2  greater 
pressure  would  appear  to  be  necessary. 

Besides  this  distance  of  the  vessel  from  the  bone  there  is  also  an  altera- 
tion in  its  direction.  In  figure  1  the  artery  lies  above  the  bone,  so  that  a 
force  acting  vertically  from  the  front  might  smash  both  bone  and  vessel ; 
in  fig.  2  it  lies  farther  down,  already  so  far  to  the  side  of  the  femur,  taking 
its  course  outwards,  that  a  force  acting  in  the  same  direction  might  wound 
the  artery  without  injuring  the  bone,  or  the  contrary. 

Moreover  the  position  of  the  artery  to  the  vein  changes  during  its 
course.  Commencing  at  the  abdominal  cavity,  the  main  trunks  lie  alter- 
nately in  the  sagittal  and  frontal  planes.  The  abdominal  aorta  lies  on  the 
lumbar  vertebra  close  to  the  vena  cava.  In  the  abdominal  cavity  the  iliac 
artery  lies  in  front  of  its  vein,  at  the  inner  border  of  the  psoas ;  and  then, 
after  passing  below  the  crural  arch,  lies  to  the  side  of  the  vein.  The 
vessels,  however,  soon  again  change  their  relation,  for  below  the  fossa 
ovalis,  as  is  seen  in  fig.  2,  the  vein  lies  below  the  artery  and  accompanies 
it  to  the  knee ;  so  that,  in  attempting  to  reach  the  popliteal  artery  from 
behind,  the  vein  would  be  in  danger  of  being  wounded,  and  must  be  pushed 
aside  in  order  to  render  the  artery  accessible. 


fig.I- 


Tah.XXI. 


'"••"' <*'<••!  J,,.,,v 


V. 


PLATE    XXI 

FIG.  1  of  this  plate  is  a  section  of  the  thigh  taken  somewhat  below  the 
upper  third,  about  2'5  inches  below  the  section  shown  in  the  preceding 
plate,  and  three  inches  below  the  trochanter  minor. 

The  individual  portions  of  the  quadriceps  extensor  are  clearly  seen 
separated  from  each  other  by  fascia.  At  the  posterior  border  of  the 
vastus  externus,  which  is  covered  by  the  strong  dense  fascial  tendon  of 
the  tensor  vaginas  femoris,  is  the  termination  of  the  gluteus  maximus. 
This  muscle  is  attached  by  means  of  a  strong  tendinous  mass  to  the 
thigh  bone,  and  here  separates  the  flexor  muscles  from  the  extensors. 

Of  the  flexors  which  accompany  the  ischiatic  nerve  the  biceps  and 
semitendinosus  are  now  completely  separate. 

The  semimembranosus  has  already  become  muscular.  Over  it  lie  the 
three  adductors — first,  the  adductor  magnus ;  upon  it  the  adductor  brevis  ; 
and  between  this  and  the  adductor  longus  the  profunda  artery  and  obtu- 
rator nerve. 

On  the  other  side  of  the  adductor  longus,  between  it  and  the  vastus 
internus,  is  the  space  for  the  femoral  artery  and  vein.  The  sheath  of  the 
vessel  is  clearly  seen ;  its  formation  by  fascial  laminae ;  and  its  closing-in 
by  the  sartorius,  which  continually  approaches  the  inner  side  of  the  thigh. 
This  muscle  reaches  the  gracilis,  to  which  it  is  very  similar  in  form,  getting 
closer  and  closer  to  it  until  at  last  the  two  muscles  accompany  each  other. 

Fig.  2  represents  a  section  through  the  middle  of  the  thigh,  where  the 
sartorius  and  gracilis  meet,  and  the  short  head  of  the  biceps  begins  to  take 
the  place  of  the  gluteus  in  the  external  intermuscular  ligament,  between 
the  vastus  externus  and  the  flexors.  External  to  the  rectus  femoris  the 
individual  portions  of  the  quadriceps  are  not  seen  any  more,  the  rectus 
with  its  central  tendon  being  completely  isolated  by  fascia. 

21 


162  PLATE   XXI 

The  femoral  artery,  Avhich  begins  to  lie  considerably  more  laterally  with 
regard  to  the  bone,  is  still  in  the  same  fascial  sheath,  between  the  adductor 
longus  and  vastus  internus,  and  covered  by  the  sartorius.  The  adductor 
longus  has  already  lost  its  bulk ;  and  the  adductor  brevis  has  disappeared 
at  this  level  entirely. 

The  profunda  artery  is  divided  at  the  point  where  it  perforates  the 
adductor  magnus  close  to  the  bone. 

The  three  flexor  muscles  are  completely  isolated  from  each  other,  and 
lie  so  close  together  posteriorly  that  the  great  sciatic  nerve  takes  a  position 
in  a  furrow  between  the  long  head  of  the  biceps  and  the  semi-tendinosus. 

With  reference  to  this  plate,  it  may  be  added  that  the  thigh  was 
rotated  somewhat  outwards  before  the  section  was  made. 


Tab.  YX1I. 


Figl 


PLATE    XXII 

THIS  and  the  following  plates  are  taken  from  sections  from  another 
body,  but  can  be  used  equally  well  in  the  series.  The  arteries  were  injected, 
the  body  frozen  lying  on  the  back,  and  the  lower  extremities  left  in  their 
normal  position,  i.  e.  somewhat  rotated  outwards. 

'  Fig.  1.  The  section  here  passed  through  the  lower  third  of  the  thigh 
nearly  a  hand's  breadth  above  the  upper  border  of  the  knee,  at  the 
position  of  the  passage  of  the  artery  through  the  adductor  opening.  The 
plate  represents  the  left  thigh,  and  the  upper  surface  of  the  lower  portion ; 
the  external  aspect  of  the  extremity  being  to  the  left,  and  the  internal  to 
the  right. 

The  adductor  longus  is  not  seen,  as  it  terminated  just  above  the  line  of 
section.  Of  the  adductors  the  magnus  only  is  present ;  its  section  is 
associated  with  the  great  vessels.  It  is  no  longer  attached  to  the  linea 
aspera,  but  all  the  muscular  tissue  to  be  seen  here  passes  directly  into 
its  tendon,  which  terminates  at  the  internal  condyle  of  the  femur. 

This  is  exactly  the  spot  where  the  artery  passes  through  the  adductor 
opening,  in  order  to  reach  the  back  of  the  bone.  The  artery  itself  lies 
surrounded  by  a  system  of  veins,  which  render  ligature  a  matter  of 
difficulty,  on  account  of  their  free  anastomosis.  Between  the  artery  and 
the  bone  lies  the  vein,  with  two  small  ones  opening  into  it;  on  the 
opposite  side  are  two  venae  comites,  which  are  lodged  between  the  artery 
and  the  long  saphena  nerve.  If  the  artery  be  tied  at  this  level,  the 
incision  must  be  made  between  the  sartorius  and  the  internal  vastus,  but 
upon  the  outer  side  of  the  former;  the  strong  dense  fascia  under  the 
sartorius  must  be  divided;  and  the  saphena  nerve  and  vense  comites 
pulled  on  one  side ;  there  is  thus  more  difficulty  in  reaching  and  isolating 
the  artery  in  this  place  than  higher  up  (vide  Plates  XX  and  XXI). 


164  PLATE   XXII 

It  is  not  correct  to  describe  the  course  of  the  artery  as  spiral  with 
regard  to  the  bone.  It  lies  certainly  in  front  of  the  bone  above,  in  the 
middle  of  it  farther  down,  and  at  the  knee-joint  completely  behind  it.  One 
can  convince  oneself  on  any  preparation,  whether  the  artery  be  injected  or 
not,  that  the  artery  passes  downwards  in  a  tolerably  straight  direction ;  it 
is  the  bone  on  the  contrary  that  describes  a  twist  round  the  artery.  The 
relation  of  the  artery  to  the  sartorius  is  constant  throughout  the  entire 
length  of  the  thigh. 

•The  great  sciatic  nerve,  like  the  artery,  has  changed  its  position  from 
the  upper  section.  As  higher  up  it  lay  behind  the  adductor  magnus,  so  here 
it  will  be  seen  behind  the  short  head  of  the  biceps.  There  is  nothing 
further  to  say  about  the  muscles.  The  prominence  of  the  central 
tendinous  intersections  indicates  the  termination  of  the  muscles,  as  well 
as  forming  the  separation  between  the  individual  portions  of  the  quadriceps, 
which  higher  up  were  separated  by  fascia. 

Fig.  2  is  a  section  of  the  left  knee-joint  through  the  centre  of  the 
patella.  The  man,  whose  lower  extremity  afforded  the  preparation,  had 
been  a  mason,  and  had  probably  knelt  a  great  deal.  At  all  events  the 
large  development  and  width  of  the  prsepatellar  bursa  would  suggest  it.  The 
patella  lies  with  the  external  portion  of  its  posterior  articular  surface  so  close 
to  the  external  condyle  of  the  femur,  that  only  a  narrow  chink  separates 
them ;  while  on  the  other  hand  it  is  raised  from  off  the  external  condyle. 
The  synovial  cavity  is  divided  by  means  of  the  ligamentum  mucosum  into 
two  portions ;  of  these,  one  follows  the  patellar  surface  and  passes  upwards 
and  inwards,  whilst  the  other  is  applied  over  the  inner  condyle.  This 
position  of  the  patella  upon  the  condyles  renders  it  clear  why  in  dislocation 
it  glides  by  preference  over  the  external  condyle.  The  position  itself  is 
conditional  on  the  curving  inwards  of  the  femur,  so  that  the  action  of  the 
powerful  extensor  muscles  alone  would  cause  the  patella  to  glide  outwards 
from  off  the  flat  hollow  between  the  condyles,  if  these  lateral  tendinous 
masses  did  not  securely  hold  it  in  position.  These  structures  are  interwoven 
as  fibrous  bundles  with  the  lateral  flat  tendinous  expansions  which  pass  from 
the  great  extensor  downwards  to  the  leg,  and  assist  in  transmitting  the 
power  of  extension  beyond  the  patella  and  ligamentum  patellae.  In  fracture 


PLATE   XXII  165 

of  the  patella  they  keep  the  fragments  in  position ;  and,  if  the  fracture  of 
the  bone  be  transverse,  they  are  torn  simultaneously  with  it.  If  the 
patella  be  sawn  through,  on  the  body,  maintaining,  however,  these  lateral 
ligamentous  structures,  and  the  leg  be  flexed,  the  halves  of  the  patella 
separate  slightly  from  each  other ;  if,  however,  they  be  divided  in  addition, 
there  immediately  ensues  a  very  wide  separation  of  the  fragments.  "We  can 
thus  understand  why  stellate  fractures  of  the  patella  unite  by  bone,  as  in 
this  instance  the  patella  alone  is  involved ;  whereas  in  transverse  fracture 
the  ligaments  are  also  torn,  the  extensor  muscles  dislocating  the  upper 
fragment. 

The  plate  shows  broad  ligamentous  bands  passing  from  the  patella  to 
both  sides  of  the  femur,  and  surrounding  the  entire  knee-joint  anteriorly 
and  laterally. 

Behind  the  articular  surfaces  of  the  condyles  is  the  expansion  of  the 
synovial  cavity  between  the  crucial  ligaments.  The  nerve,  artery,  and 
vein,  lie  close  behind  each  other,  the  former  being  more  external ;  the  sciatic 
nerve  dividing  into  the  external  popliteal  inside  and  below  the  biceps,  and 
the  internal  popliteal  more  towards  the  middle. 

The  muscles,  which  in  fig.  1  showed  such  fleshy  masses,  are  here 
confined  and  diminished  in  bulk.  They  are  for  the  most  part  completely 
reduced  to  tendon  ;  and  the  defined  form  of  contour,  which  is  characteristic 
of  the  region  of  the  knee-joint,  is  dependent  on  that  of  the  bones. 

In  synovitis,  the  patella  would  be  lifted  off  the  articular  surface  of  the 
thigh  bone,  the  distension  of  the  capsule  being  especially  evident  in  front. 
The  posterior  parts  are  but  slightly  yielding,  and  are  consequently  only 
slightly  separated  from  the  posterior  surfaces  of  the  condyles. 


PLATE    XXIII 

FIG.  1  is  a  section  through  the  upper  third  of  the  leg  taken  from  the 
same  subject  as  the  last. 

Similar  plates  will  be  found  in  Volz  (a  a  0,  taf.  ix,  fig.  1)  and  in  Pirogoff 
(fasc.  4,  tab.  viii,  fig.  8), 

The  strong  framework  from  which  the  muscles  spring  is  formed  by  the 
tibia  and  fibula,  the  inter-osseous  membrane,  the  strong  fibular  inter- 
muscular  aponeurosis,  which  passes  obliquely  outwards  and  forwards  from 
the  fibula  between  the  peroneal  and  extensor  muscles,  and  the  dense  fascia, 
from  which  the  fibres  of  the  tibialis  anticus  in  particular  arise. 

The  strongly  developed  muscles  divide  themselves  into  three  groups. 
Anteriorly  are  the  extensors,  tibialis  anticus,  and  extensor  communis 
digitorum  bounded  behind  by  the  interosseous  membrane,  the  extensor 
longus  pollicis  is  not  yet  seen,  as  it  arises  lower  down.  Externally  and 
lying  on  the  fibula  is  the  peroneus  longus,  which  belongs  to  the  second 
group  separated  from  the  extensor  communis  by  the  intermuscular  ligament. 
Posteriorly  to  both  bones  is  the  third  group,  in  which  the  flexors  pre- 
ponderate, and  their  deep  layer  is  analogous  to  that  of  the  extensor  side  in 
having  only  two  muscles. 

The  tibialis  posticus  lies  on  the  interosseous  ligament  between  the  tibia 
and  fibula,  and  the  flexor  longus  digitorum,  of  which  only  a  small  portion  is 
seen,  on  the  tibia.  Behind  them  are  the  large  expanded  surfaces  of  the 
soleus  and  gastrocnemius,  and  on  the  posterior  aspect  of  the  tibia  is  a  strip 
of  the  popliteus.  This  muscle  lies  almost  entirely  between  this  and  the  last 
section  (Plate  XXII). 

The  nerves  belonging  to  the  three  groups  are  marked  white.  The 
superficial  peroneal  nerve  lies  between  the  peroneus  longus  and  the  fibula; 
and  the  deep  peroneal  nerve,  which  is  separated  from  it  by  the  fibular  inter- 


TakXXffl 


'"  ST. 


PLATE   XXIII  167 

muscular  septum  lies  on  the  interosseous  ligament  and  fibula.  The  posterior 
tibial  nerve  is  seen  between  the  flexor  longus  pollicis  and  the  soleus. 

The  three  arteries,  the  anterior  tibial,  posterior  tibial  and  peroneal,  are 
seen  together  with  their  veins.  The  two  latter  arteries  lie  close  to  each  other, 
as  the  section  passed  immediately  below  their  origins,  separated  from  the 
interosseous  ligament  by  the  tibialis  posticus,  and  they  divide  the  deep  layer 
of  the  flexor  group  from  the  muscles  of  the  calf  which  form  the  superior 
layer.  The  anterior  tibial  artery  lies  on  the  interosseous  membrane.  The 
furrow  running  between  the  tibialis  anticus  and  extensor  digitorum  longus 
indicates  the  position  of  this  vessel,  hence  it  may  be  readily  found,  its  depth 
being  the  only  difficulty. 

Fig.  2.  This  section  through  the  middle  of  the  left  leg  may  be 
compared  with  the  plates  of  Henle  ('  Muskellehre,'  fig.  142),  and  Voltz 
(a  a  0,  tab.  ix,  fig.  2). 

The  relations  of  the  muscles,  vessels  and  nerves  can  be  so  readily  made 
out  that  it  does  not  seem  worth  while  explaining  the  plate. 

Beneath  the  muscles  of  the  calf,  in  this  section,  all  the  flexors  are  seen 
together.  The  flexor  longus  digitorum  has  now  considerable  bulk,  and  so 
also  has  the  flexor  longus  pollicis,  which  has  already  the  peroneal  artery 
between  it  and  the  fibula ;  and  the  anterior  tibial  artery  lies  between  the 
extensor  communis  and  the  tibialis  anticus.  The  artery  is  still  so  deep 
that  its  ligature  at  this  place,  though  practicable,  is  not  to  be  recommended. 
Farther  down,  and  nearer  the  ankle,  the  muscular  tissue  ceases  somewhat, 
and  the  vessel  is  more  easily  reached. 

The  peronei  muscles  are  completely  developed,  and  the  superficial 
peroneal  nerve  is  already  approaching  so  near  the  surface  that  it  seems 
about  to  perforate  the  fascia. 

If  the  two  sections  be  compared  which  represent  the  position  of  the 
individual  structures  in  the  upper  half  of  the  leg,  the  superficial  position  of 
the  tibia  is  evident  and  can  be  readily  felt,  hence  affections  of  this  bone  from 
disease  and  accident  are  easy  of  diagnosis.  The  fibula,  on  the  other  hand, 
is  unfortunately  situated  in  this  respect.  The  thick  masses  of  the  surround- 
ing muscles  do  not  favour  its  examination,  and  we  must  in  its  instance  use 
some  other  diagnostic  means,  such  as  fixed,  deep-seated  pain. 


168  PLATE   XXIII 

The  course  the  knife  must  take  in  order  to  expose  the  fibula  is 
indicated  by  the  fibular  intermuscular  septum.  The  muscles  which  bound 
this  septum,  the  peroneus  brevis  and  extensor  proprius  pollicis,  are  easily 
made  out  at  the  outer  surface  of  the  bone,  and  the  plate  assists  the  surgeon 
in  judging  of  the  depth  the  wound  should  be  in  muscular  individuals.  In 
this  proceeding  no  vessels  of  large  size  will  be  met  with,  but  the  peroneal 
nerve  must  be  carefully  avoided,  as  it  would  fall  in  the  line  of  incision. 

The  superficial  position  of  the  tibia  also  demands  attention  with  regard 
to  the  treatment  of  ulcers,  as  the  periosteum  is  all  the  more  likely  to  be 
involved  the  fat  being  so  sparingly  developed,  whilst  in  almost  all  other 
points  of  the  section  it  is  more  abundant  and  consequently  the  skin  is 
further  from  the  subjacent  fasciae. 

The  main  arteries,  with  their  accompanying  veins,  at  this  level  are  still 
tolerably  near  their  origins,  and  not  very  far  separated  from  each  other. 
In  the  inner  portion  of  the  section  they  lie  so  near  the  interosseous 
ligament,  and  are  so  protected  from  external  pressure  by  the  bones  of  the 
leg,  that  they  are  not  so  liable  to  be  wounded  as  elsewhere.  At  the  same 
time  from  their  position  they  are  not  readily  compressible  against  the 
skeleton,  so  that  in  amputation  or  any  operation  where  much  bleeding  is 
expected  a  toiirniquet  must  be  applied  above  the  knee. 


PLATE    XXIV 

• 

FIG.  1  represents  a  section  through  the  lower  third  of  the  left  leg  near 
the  joint.  From  the  decrease  in  the  masses  of  the  muscles  and  the  increase 
of  the  tendinous  structures  the  section  of  the  limb  has  become  considerably 
smaller.  Although  individual  muscles,  such  as  the  extensor  and  flexor 
longus  pollicis  with  the  peroneus  brevis,  have  become  stronger  than  in 
the  preceding  plate,  they  do  not  make  up  for  the  want  of  those  of  the 
calf  which  determine  the  size  and  shape  of  the  leg.  The  soleus  and 
gastrocnemius  are  no  longer  separate,  a  longitudinally  directed  tendinous 
mass  spreads  over  the  posterior  surface  of  the  soleus ;  this  is  the  termina- 
tion of  the  gastrocnemius,  which  becoming  blended  with  the  fibres  of  the 
soleus,  forms  the  tendo  Achillis. 

The  largest  surface  shown  is  that  of  the  flexor  longus  pollicis,  which 
is  here  divided  at  its  greatest  bulk.  In  flexing  the  great  toe  in  walking 
this  muscle  contracts  so  forcibly  that  its  power  exceeds  that  of  the 
other  flexors  of  the  toes.  Its  position  has  altered  from  the  last  plate, 
being  further  back  and  more  beneath  the  tibialis  posticus,  so  that  after  com- 
pletely crossing  it  in  the  malleolar  region  it  lies  at  last  most  internally. 

The  position  of  the  deep  flexors  is  essentially  distinct  from  that  of  the 
extensors.  The  tibialis  anticus  lies  close  on  the  tibia,  and  gains  the  inner 
border  of  the  foot  without  crossing  its  neighbours,  the  extensor  longus 
pollicis  and  extensor  communis  digitorum ;  whilst  the  tibialis  posticus  lies 
in  the  middle  on  the  interosseous  ligament,  the  flexor  longus  pollicis 
on  the  fibula,  and  the  flexor  longus  digitorum  on  the  tibia,  and  these 
muscles  cross  each  other  before  their  ultimate  insertion.  This  position 
is  connected  with  their  passage  at  the  inner  malleolus.  As  they  are 

22 


170  PLATE   XXIV 

pushed  aside  by  the  sustentaculum  -tali,  they  would  obtain  a  very  insuffi- 
cient hold  beneath  the  short  internal  malleolus  if  the  flexor  longus 
pollicis  and  tibialis  posticus  lay  on  the  inner  border  of  the  leg,  and  if 
the  flexor  longus  digitorum  arose  from  the  fibula  it  would  act  at  a  great 
disadvantage.  This  defect  is  remedied  in  a  simple  manner  by  the  crossing 
of  the  tendons. 

The  arteries  have  the  same  muscular  separations  as  before,  notwith- 
standing that  they  have  materially  altered  their  position  with  regard  to  the 
tibia ;  and,  in  consequence  of  the  diminution  of  the  bulk  of  the  overlying 
muscles  they  are  considerably  nearer  the  surface,  so  that  their  ligature  is 
easier  than  above.  The  anterior  tibial  artery  can  be  reached  between  the 
tibialis  anticus  and  extensor  longus  pollicis,  and  the  posterior  tibial  can  be 
readily  found  if  the  border  of  the  soleus  be  detached  and  pulled  back 
from  the  flexor  longus  digitorum.  The  position  of  the  peroneal  artery  is 
the  most  unfavorable  for  ligature,  as  it  must  be  searched  for  behind  the 
peronei,  after  separating  the  flexor  longus  pollicis  from  the  fibula,  when  it 
can  be  drawn  out  from  behind  the  bone. 

Fig.  2.  This  section  of  the  leg  in  the  region  of  the  malleolus  terminates 
this  series.  It  divides  the  tibia  and  fibula  immediately  above  the  astragalus, 
hence  the  comparatively  large  size  of  the  tibia.  Both  are  strongly  bound 
together  by  ligaments,  and  in  front  is  an  opening  into  the  cavity  of  the 
ankle-joint. 

The  muscles  now  almost  entirely  present  their  tendons,  only  the  outer 
portion  of  the  extensor  of  the  toes,  the  peroneus  tertius,  and  the  extensor 
flexor  longus  pollicis,  still  show  muscular  tissue.  With  the  tendons  are 
associated  their  bursse  which  are  shown  as  dark  chinks,  and  the  ligamentous 
apparatus  which  renders  secure  the  position  of  these  tendons  at  the  ankle. 
The  upper  portion  of  the  annular  ligament  is  met  with,  the  point  of  origin 
of  which  from  the  os  calcis  lies  deeper  and  is  consequently  not  seen, 
and  under  the  middle  fasciculus  which  encloses  the  extensor  longus  pollicis, 
lies  the  anterior  tibial  artery  which  may  be  here  readily  reached  from  the 
surface.  To  expose  the  posterior  tibial  artery  for  ligature,  the  division 
of  one  fasciculus  only  of  the  internal  annular  ligament  is  necessary.  It 
lies  between  the  flexor  longus  digitorum  and  flexor  longus  pollicis,  and  the 


PLATE   XXIV  171 

bursal  sheaths  of  both  muscles  can  be  completely  avoided  in  looking  for 
the  artery.  The  tendo  Achillis  lies  some  way  further  back,  so  that  its 
division  is  easily  accomplished  without  wounding  the  vessel. 

The  two  plates  here  given  are  sufficient  to  show  the  most  important 
points  in  the  lower  half  of 'the  leg.  On  the  other  hand,  the  relations  given 
of  the  foot  are  insufficient,  and  perhaps  a  further  series  of  sections  might 
have  been  shown.  From  numbers  of  sections  which  I  have  made  and 
had  drawn,  and  have  before  me,  as  well  also  from  the  examination  of 
Pirogoff's  plates,  I  have  come  to  the  conclusion,  that  sections  of  the 
foot  are  not  of  very  much  use  for  the  comprehension  of  its  structure, 
although  a  clear  idea  of  the  arrangement  and  form  of  its  bony  arches  may 
be  obtained ;  but  for  the  relations  of  the  soft  parts  they  are  only  of  sub- 
ordinate importance.  Flat  preparations  are  in  this  respect  of  more  value 
and  are  indispensable.  The  numerous  small  muscular  masses  of  the 
sole  are  divided  from  each  other  merely  by  fasciae  and  cellular  tissue,  and 
the  number  of  tendons  on  the  dorsum  which  can  be  but  inadequately 
separated  from  the  ligaments  by  transverse  section,  would  give  unre- 
liable plates.  Again,  the  arrangement  of  the  annular  ligament  would  be 
absolutely  unintelligible  if  studied  on  sections  only.  The  arteries,  as 
has  already  been  mentioned  in  fig.  1,  lie  much  nearer  the  surface  than 
in  the  preceding  plate,  and  therefore  have  far  simpler  landmarks  for 
their  ligature  than  in  the  upper  half  of  the  leg.  They  form  a  triangle 
with  two  nearly  equal  sides.  The  base  of  this  triangle  is  formed  by 
a  line  passing  from  the  anterior  tibial  artery  to  the  peroneal,  directed 
outwards,  as  seen  in  fig.  1.  This  arterial  triangle,  in  consequence 
of  the  termination  of  the  peroneal  artery,  ceases  in  fig.  2,  and  is  not 
seen  in  Plate  XXIII,  fig.  1.  On  the  other  hand,  it  is  very  clear  from 
Plate  XXIII,  fig.  2,  that  if  this  triangle  be  compared  in  this  and 
the  preceding  plate,  the  direction  of  its  base  and  the  length  of  its  sides 
remain  exactly  the  same.  It  so  happens  that  these  arteries  in  their  course 
in  the  lower  half  of  the  leg  remain  in  the  same  position  with  regard  to 
each  other ;  and  that  they  run  as  parallel  vascular  tubes,  and  do  not 
from  their  own  change  of  position  get  nearer  the  surface,  but  from  the  con- 
tinually decreasing  masses  of  the  muscles  as  they  proceed  downwards. 


THE  accompanying  frontal  section  of  the  thorax  and  shoulder- joints 
was  made  from  the  body  of  a  very  powerful  man.  Beyond  the  enlarged 
thyroid  body  there  was  nothing  abnormal.  From  the  recumbent  position 
of  the  body,  particular  regard  was  taken  of  the  upper  extremity,  and  it 
appeared  desirable  to  divide  the  humeri  in  their  long  axes,  and  the  arms  being 
placed  in  the  position  they  would  have  held  in  the  upright  position  were 
rolled  outwards  so  that  the  bicipital  groove  was  directed  forwards.  After 
being  frozen  in  this  position,  tne  head  was  removed  from  the  neck  just  below 
the  larynx,  and  the  rest  of  the  body  separated  by  a  section  through  the 
nipples.  The  frontal  section  was  so  directed  that  it  passed  through  the 
middle  of  the  heads  of  the  humeri  and  their  shafts. 

Before  freezing,  the  arteries  were  injected  from  the  femoral. 

The  cupolas  of  the  lungs  are  divided  thro  ugh  their  highest  points.  Both 
subclavian  arteries  pass  over  the  cupolae  of  the  lungs,  and  consequently 
cause  an  impression  on  the  pleura,  which  on  examining  the  cavity  of  the 
chest  can  be  readily  recognised. 

The  arteries,  however,  do  not  cross  the  cupolae  of  the  lungs  at  their 
highest  points.  They  lie  considerably  behind  them  and  below  the  brachial 
plexus  in  the  neighbourhood  of  the  head  of  the  first  rib.  The  section  has 
passed  through  the  arch  of  the  right  subclavian  artery,  but  not  disturbed 
the  left,  running  in  front  of  it  as  is  clearly  seen  in  the  plate.  The 
preparation  showed  on  further  examination  that  the  lungs  and  pleural 
cavities  extended  considerably  further  up.  The  first  ribs  were  divided  at 
their  anterior  extremities,  the  right  behind  the  origin  of  the  scalenus  anticus, 
the  left  immediately  through  its  origin. 

The  roots  of  the  lungs  lie  behind  the  section,  the  left  further  from  its 
plane  than  the  right. 


- 


PLATE   XXV  173 

Corresponding  with  this,  on  the  left  side  of  the  plate,  there  is  no  inter- 
ruption of  the  pleura,  whilst  on  the  right  side  (to  the  left  of  the  spectator), 
the  points  of  reflexion  of  this  membrane  have  fallen  in  the  section.  The 
relations  are  complicated  by  the  pericardium.  Between  the  lungs  and 
heart  there  are  seen  two  spaces,  which  are  the  cavities  of  the  pericardium 
and  pleurse. 

The  left  ventricle  is  opened,  and  a  portion  of  the  right  auricle  is  shown. 
In  connection  with  them  are  seen  the  aorta  and  superior  vena  cava  in 
section.  The  former  is  exposed  for  its  whole  extent,  so  that  the  entrance 
from  behind  of  the  azygos  major  vein  appears.  In  continuation  of  the 
superior  cava  is  the  right  innominate  vein,  which  as  it  passes  more  verti- 
cally, is  divided  throughout,  and  the  two  delicate  valves  are  seen.  The  left 
innominate  vein,  which  passes  more  obliquely,  was  removed  with  the  other 
half  of  the  body.  Its  end  only  is  shown,  at  the  point  of  entrance  of  the  left 
subclavian  vein  as  a  large  venous  lumen  immediately  above  the  first  rib. 

The  aorta  is  exposed  in  the  horizontal  portion  of  its  arch.  At  its 
origin  it  shows  a  considerable  swelling  of  the  bulbus  aortsB,  produced  by 
the  pressure  of  the  injection  on  the  semilunar  valves,  of  which  two,  one 
nearly  bisected,  are  seen.  Below  them,  in  the  left  ventricle,  is  the  aortic 
segment  of  the  mitral  valve.  The  liquor  pericardii  had  collected  in  the 
upper  portion  of  the  pericardium. 

It  will  be  observed  from  the  free  surface  afforded  by  the  divided 
left  auricular  appendix  above  the  left  ventricle,  that  the  two  laminae 
of  the  pericardium  are  considerably  separated  from  each  other  in  this 
situation,  whilst  in  all  other  places  they  are  directly  in  apposition,  so  that 
its  cavity  is  shown  only  as  a  crevice.  Between  the  left  ventricle  and 
the  ascending  aorta  is  the  section  of  the  pulmonary  artery,  which  being 
nearly  horizontal,  is  divided  transversely.  The  vessel  is  seen  from  before 
backwards,  and  the  lumen  of  the  right  branch  is  exposed,  curving  sharply 
behind  the  aorta,  to  reach  the  root  of  the  right  lung ;  whilst  the  left  branch 
passes  obliquely  upwards  and  outwards,  to  course  over  the  left  bronchus 
and  root  of  the  left  lung. 

The  position  of  the  great  vessels  given  off  from  the  aorta  is  considerably 
altered  by  the  hypertrophied  thyroid  gland.  This,  as  the  plate  shows,  has 


174  PLATE   XXV 

compressed  the  trachea  on  both  sides ;  and  very  probably  interfered  wit! 
deglutition  from  pressure  on  the  oesophagus.  It  involved  the  interspace 
that  the  two  carotids  form  with  the  aorta,  and  pushed  them  asunder.  I] 
the  left  carotid,  which  is  freely  divided,  this  is  clearly  seen ;  whilst  in  th 
right  a  small  portion  only  of  its  origin  from  the  innominate  is  involved,  a 
it  lay  almost  entirely  in  the  anterior  half  of  the  preparation. 

The  subclavian  artery  of  the  left  side  is  not  seen,  as  it  takes  its  origii 
from  the  arch  of  the  aorta  behind  the  carotid ;  it  lay  in  this  preparatioi 
behind  the  section,  covered  by  the  pectoralis  minor.  Its  continuation,  tb 
brachial  artery,  came  into  the  line  of  section,  and  is  to  be  seen  between  it 
accompanying  nerves. 

On  the  right  side  is  seen,  on  the  other  hand,  the  continuation  of  th 
innominate  artery  into  subclavian  and  axillary.  The  arch  of  the  right  sub 
clavian  passes  under  the  right  innominate  vein,  over  the  cupola  of  th 
right  lung ;  and  gives  off  anteriorly  the  internal  mammary  artery,  which  i 
here  transversely  divided,  and  the  inferior  thyroid  which  is  slit  up  am 
covered  at  its  extremity  by  the  thyroid  body ;  passes  over  the  first  rib  fron 
within  outwards ;  and  finally  disappears  behind  the  cut  surface  of  th 
coraco-brachialis. 

The  subclavian  veins  correspond  on  both  sides.  The  right  subclaviai 
vein  is  cut  short  off  above  the  second  rib,  and  the  left  is  widely  opene< 
between  the  scalenus  anticus  and  pectoralis  minor.  The  latter,  whicl 
receives  many  small  veins,  is  of  large  calibre,  and  passes  with  its  inne 
wall  rather  more  upwards,  towards  the  internal  jugular  vein  which  lie 
on  the  outer  side  of  the  carotid  artery.  Of  the  internal  jugular  vein  o 
the  right  side  nothing  is  to  be  seen,  the  parts  being  entirely  removed  wit] 
the  anterior  half  of  the  body.  The  left  subclavian  vein  consequently  lie 
farther  forward  than  the  right. 

The  right  brachial  plexus  is  exposed  throughout  its  length,  whilst  th 
left  is  covered  and  only  its  commencement  is  seen  under  the  anterio 
scalene  muscle. 

The  several  structures  of  the  neck  group  themselves  about  the  fifth 
sixth,  and  seventh  cervical  vertebrae.  At  the  lower  border  of  the  seventl 
cervical  are  the  cut  surfaces  of  the  longi  colli  muscles,  which  lie  betweei 


PLATE   XXY  175 

the  spine  and  the  thyroid  gland.  Above  both  muscles,  on  either  side  of  the 
bodies  of  the  vertebrae,  are  the  vertebral  arteries  slit  open  ;  of  these  the  left 
shows  a  far  larger  calibre  than  the  right.  From  behind  these  vessels 
proceed  the  roots  of  the  brachial  plexus,  which  is  entirely  covered  on  the 
left  side,  and  partly  on  the  right,  by  the  cut  surfaces  of  the  scaleni.  Still 
more  externally  and  upwards  are  the  sections  of  the  sterno-cleido-mastoids, 
with  a  strip  of  the  platysma,  immediately  beneath  which  on  both  sides  is 
the  external  jugular  vein. 

The  right  phrenic  nerve  is  completely  removed ;  the  left  is  seen  between 
the  carotid  artery  and  the  lung.  The  artery  accompanying  it  is  the  internal 
mammary. 

The  vagus  is  only  partially  cut  on  the  left  side,  where  it  lies  in  front 
of  the  arch  of  the  aorta,  and  from  whence  its  recurrent  branch  passes 
upwards  behind  that  vessel.  On  the  right  side,  on  the  contrary,  it  is 
divided  transversely  at  the  point  where  it  is  applied  to  the  root  of  the 
lung. 

The  shoulder- joints  have  so  fallen  into  the  section  that  the  saw  has  passed 
on  both  sides  in  front  of  the  glenoid  cavities ;  and  nothing  is  seen  of  the 
scapular  element  of  these  articulations.  The  bony  elements  of  this  portion  of 
the  joint  He  behind  the  plane  which  passes  through  the  middle  point  of  the 
head  of  the  humerus.  On  the  left  side  the  glenoid  cavity  was  only  a  quarter 
of  an  inch  behind  the  plane  of  section ;  on  the  right  it  was  so  much  closer  that 
the  limbus  cartilagineus  fell  into  it.  As  the  head  of  the  humerus  is  directed 
inwards  and  backwards  towards  the  glenoid  cavity  and  as  the  section  passes 
deeper  on  the  right  than  on  the  left,  the  greater  tuberosity  of  the  right 
side  has  been  entirely  removed.  The  round  section  of  the  head  is  all  that 
is  seen,  whereas  on  the  left  the  greater  tuberosity  projects  in  a  triangular 
form. 

On  the  right  side  a  portion  of  the  acromion  appears ;  and  on  the  left  the 
section  has  passed  more  anteriorly,  and  has  nearly  divided  the  coraco- 
acromial  ligament.  Normally  the  acromion  rises  but  very  little  above  the 
head  of  the  humerus,  so  that  anteriorly  a  tolerably  large  portion  of  the  latter 
remains  unprotected  by  bony  covering.  The  coracoid  process  is  divided 
transversely  on  either  side,  and  is  readily  seen  between  the  head  of  the 


176  PLATE   XXV 

humerus  and  the  clavicle.  It  is  cut  through  behind  the  attachments  of 
the  muscles. 

The  pectoralis  minor  on  both  sides  of  the  chest  is  divided,  and  shows  a 
large  surface  of  section,  on  the  left  side  particularly.  This  is  explained 
by  the  forward  position  of  the  shoulder,  and  by  the  muscle  becoming  relaxed 
and  folded  so  that  its  posterior  border  was  bent  backwards. 

The  strongly  curved  clavicle  has  a  different  appearance  on  the  two  sides. 
The  right,  which  projects  further  forwards,  shows  beyond  the  section  its 
entire  acromial  end,  whereas  on  the  left  side  this  is  not  seen.  The  section 
of  the  clavicular  portion  of  the  deltoid  of  this  side  is  shown.  On  the  right 
side  the  anterior  attachment  of  this  muscle  is  completely  removed.  Its 
attachment  to  the  humerus  is  equally  divided  on  both  sides  ;  and  the  bursa 
between  it  and  the  capsular  ligament  appears  as  a  black  line. 

With  regard  to  the  relations  of  this  capsule,  the  following  points  are  to 
be  noticed.  Since  the  shoulder-joint  is  under  the  influence  of  atmospheric 
pressure,  the  bone  is  pressed  against  the  glenoid  cavity;  and  therefore 
the  cavity  of  the  joint  notwithstanding  its  extent  and  the  laxity  of  its 
capsule  can  be  shown  merely  as  a  crevice  in  the  representation  of  its 
section.  The  ligamentous  tissue  which  terminates  at  the  neck  of  the 
humerus  is  the  capsule :  this,  on  the  left  side,  encircles  the  bone  like 
a  ring  from  the  greater  tuberosity,  and  encloses  the  obliquely  divided 
tendon  of  the  biceps  superiorly;  these  relations  on  the  right  side  are 
shown  rather  differently.  In  the  first  place,  a  portion  of  the  limbus  carti- 
lagineus  is  seen,  terminating  above  in  a  sharp  angle,  and  externally  the 
supra-spinatus  presents  itself  in  section  strengthening  the  capsule  by 
its  tendon,  and  which  more  externally  is  so  closely  united  with  the  tendons 
of  the  infra- spinatus  and  the  teres  minor  that  no  line  of  separation  can  be 
represented. 

On  the  inner  side  of  the  neck  the  capsule  is  more  loosely  attached,  so 
that  by  raising  the  humerus  its  folds  are  obliterated. 

The  limit  of  the  capsule  towards  the  middle  line  is  formed  by  the  sub- 
scapularis,  which  is  seen  divided  on  both  sides.  Beneath  it  lies  its  bursa, 
which  must  be  looked  for  between  it  and  the  capsule.  It  normally  forms  a 
communication  with  the  cavity  of  the  joint,  but  which  was  not  seen  in  this 


PLATE   XXV 


377 


section.  Nevertheless  the  outer  side  of  the  subscapularis  is  to  be  seen  on 
the  left  shoulder-joint  limited  by  a  dark  line,  indicating  the  synovial  mem- 
brane in  section.  This  line  runs  in  a  curved  direction  with  its  concavity 
outwards,  corresponding  with  the  head  of  the  humerus. 

In  order  to  demonstrate  the  extent  of  the  cavity  of  the  capsular  liga- 
ment and  to  show  the  amount  of  separation  of  the  humerus  from  the 
scapula  when  the  joint  is  distended  by  effusion,  I  injected  some  fresh 
joints  with  tallow,  froze  them,  and  then  made  sections.  One  of  these  pre- 
parations is  shown  in  the  following  woodcut. 


Frontal  section  of  the  right  shoulder-joint,  injected  with  tallow.     Anterior  half.     5. 

1.  Head  of  humerus.     2.  Neck  of  scapula.     3.  Anterior  margin  of  scapula.    4.  Clavicle. 

5.  Deltoid.    6.  Triceps.     7.  Teres  major.     8.  Teres  minor.     9.  Infra- spinatus. 

10.  Supra- spinatus.     11.  Trapezius. 


The  humerus  is  seen  from  behind  half  extended  and  somewhat  rolled 
inwards,  a  position  it  acquired  from  the  great  pressure  of  the  injection,  and 
corresponding  with  the  greatest  amount  of  distension  of  the  capsule.  This 
injection  was  made  from  the  supra-spinous  fossa  through  the  glenoid  cavity, 
and  the  upper  arm  amputated  at  its  lower  end,  so  as  not  to  hamper  the  move- 
ments of  the  joint  by  its  weight.  It  appeared  that  the  greatest  distance  of  the 

23 


178  PLATE   XXV 

head  of  the  humerus  from  the  glenoid  cavity  was  somewhat  over  half  an 
inch ;  hence  it  would  appear  likely  that  in  inflammation  with  effusion  into 
the  cavity  of  the  joint,  there  would  be  some  considerable  lengthening  of 
the  limb. 

In  order  to  bring  the  relations  of  the  heart  more  completely  into 
notice,  it  became  necessary  to  extend  the  section  farther  downwards  than 
was  possible  in  this  preparation.  Consequently  I  made  a  series  of  sections 
to  supply  this  deficiency,  but  unfortunately  none  of  these  specimens  could 
be  used  to  supplement  this  plate. 


i" 
I 


tt 

<ob 


PLATE    XXVI 

THE  longitudinal  section  shown  in  this  plate  is  taken  through  the 
elbow-joint  and  hand  of  a  young  normal  female  subject,  with  no  previous 
injection  of  the  vessels. 

There  was  neither  artificial  injection  of  the  articulation  nor  any  pre- 
determined position  thereof.  It  was  frozen  and  sawn  through  in  its 
normal  condition. 

Figure  1.  In  this  plate  is  shown  the  sagittal  section  of  the  right 
elbow- joint,  taken  somewhat  obliquely,  and  seen  from  the  radial  aspect. 
The  saw  has  passed  nearly  through  its  centre,  and  removed  a  small 
portion  of  the  radial  surface  of  the  ulna.  As  the  forearm  is  slightly 
bent,  and  in  semipronation,  the  radius  is  met  with  in  its  long  axis, 
a  small  portion  of  the  ulnar  aspect  of  its  head  only  remaining.  Farther 
down  its  shaft  is  divided  obliquely,  and  the  medullary  cavity  partially 
opened.  In  consequence  of  pronation  the  radius  does  not  lie  parallel 
with  the  ulna  but  crosses  it,  and  is  directed  with  its  inferior  extremity 
forwards. 

The  expansion  of  the  cavity  of  the  elbow-joint  is  worthy  of  notice  in 
flexion  and  extension  of  the  humerus.  The  folding-in  of  the  capsular  liga- 
ment in  the  posterior  supra- trochlear  fossa  corresponds  with  the  slight 
degree  of  flexion,  and  if  this  flexion  be  further  increased,  this  folding-in 
would  become  eradicated  and  take  place  on  the  anterior  aspect.  The 
cavities  above  the  trochlea  are  alternately  filled  at  the  end  of  flexion  and 
extension,  the  capsule,  however,  being  drawn  away  beforehand  by  certain 
muscles,  viz.  the  brachialis  anticus  and  biceps,  so  that  it  may  not  be 
included  between  the  bones. 

It  can  be  seen  from    the  plate  that   the  bones   do  not   lie  completely 


180  PLATE  XXYI 

in  apposition.  Injections  of  the  elbow-joint  with  strong  pressure  show 
that  it  acquires  the  position  of  semiflexion,  and  that  the  fluid  injected 
partially  separates  the  joint-surfaces. 

The  terminations  of  the  flexor  muscles  of  the  arm  are  not  seen.  The 
brachialis  anticus,  which  lies  close  upon  the  capsule,  is  divided  longitudinally, 
as  is  seen  from  the  direction  of  its  fibres ;  and  the  same  remark  applies  to 
the  biceps,  its  tendon  is  deeper  down  behind  the  radius,  and  can  be 
exposed  only  by  dissection.  The  tendinous  mass  shown  in  the  plate,  between 
the  upper  end  of  the  radius  and  the  ulna,  is  a  portion  of  the  tendon  of  the 
biceps ;  another  portion  of  it  belongs  to  the  circular  ligament  of  the  ulna, 
which  forms  the  means  of  checking  excessive  separation,  and  becomes 
broader  in  pronation.  The  triceps  at  the  back  of  the  humerus  shows 
its  complete  connection  with  the  olecranon.  On  the  anterior  surface 
of  the  biceps  is  the  supinator  brevis,  and  farther  in  front  are  portions 
of  the  supinator  longus  and  the  extensor  carpi  radialis  longior  the  heads 
of  which  are  removed  with  the  external  condyle.  No  vessels  or  nerves 
are  seen  in  the  plate,  excepting  an  obliquely  divided  vein,  a  portion  of 
the  median-cephalic,  and  the  radial  nerve  beneath  the  supinator  longus. 
The  main  artery,  with  its  accompanying  veins  and  the  median  nerve,  which 
pass  down  on  the  inner  side  of  the  arm  and  afterwards  turn  forwards  on 
the  bend  of  the  elbow,  lie  concealed  in  the  soft  parts  below  the  surface  of 
the  section. 

Sections  made  as  shown  in  this  plate  are  rarely  successful,  and  not  easy 
to  understand  at  first  sight,  since  in  complete  supination  and  parallelism 
of  the  bones  of  the  forearm — the  usual  position  from  which  descriptions 
are  made — the  radius  and  ulna  lie  in  a  frontal  plane. 

I  have,  however,  specially  chosen  the  present  position  of  the  arm  for 
the  section  as  being  the  more  normal  one  in  which  the  radius  lies  in  front 
of  the  ulna  for  almost  its  entire  length.  A  very  similar  representation  is 
to  be  found  in  Pirogoff's  Atlas  (Fasc.  iv  B,  Taf.  iv,  fig.  7). 

Frontal  sections  of  the  elbow-joint  agree  with  the  preceding  if  the 
forearm  is  completely  extended  and  supinated,  and  if,  moreover,  it  be 
forcibly  retained  in  this  position  before  freezing. 

The  radius  and  ulna  are  divided  in  their  longitudinal  axes  and  in  con- 


PLATE  XXYI  181 

tinuation  with  the  humerus.  As  Pirogoff's  and  Voltz's  Atlases  contain  an 
excellent  and  complete  series  of  such  sections,  it  seems  hardly  worth  while 
to  multiply  them  in  this  work. 

Fig.  2  is  a  longitudinal  section  of  the  right  forearm,  hand,  and  third 
finger,  from  the  same  arm  as  fig.  1,  and  is  viewed  from  the  ulnar  aspect. 
The  radius  is  divided  in  its  entire  length ;  on  its  articular  surface  is  the 
semilunar  bone,  and  in  front  of  it  the  os  magnum  and  third  metacarpal 
bone,  the  first  phalanx,  and  a  portion  of  the  second,  the  third  was  not 
included  in  the  section.  The  joints  were  not  particularly  prepared  for  the 
section.  In  the  hand  they  are  in  the  condition  of  partial  extension,  whilst 
the  fingers  are  flexed  from  the  effects  of  freezing.  The  skin  is  smooth  on 
the  dorsal  aspect,  whilst  on  the  volar,  which  is  rich  in  fat,  it  forms  thick 
pads,  giving  rise  to  deep  furrows.  During  extension  these  furrows  appear 
as  transverse  lines,  and  do  not  correspond  with  the  opposed  articular 
surfaces  of  the  joints.  Those  on  the  volar  aspect  of  the  root  of  the 
finger  lie  considerably  further  forwards  than  the  corresponding  metacarpo- 
phalangeal  joints,  and  the  subsequent  furrow  exceeds,  though  not  to  so 
great  an  extent,  the  joints  between  the  first  and  second  and  third  phalanges, 
consequently  in  disarticulation  of  a  finger  from  the  volar  aspect  the  joint 
will  not  be  opened  if  the  knife  be  applied  directly  upon  this  furrow.  The 
articulation  will  be  far  more  certainly  reached  if  the  incision  be  made  from 
the  extensor  aspect,  after  slightly  flexing  the  finger,  a  little  in  front 
of  the  projection  which  the  head  of  the  bone  makes  with  its  distal  phalanx. 
Corresponding  with  the  more  extensive  expansion  of  the  cartilage  on 
the  volar  aspect,  the  cavity  of  the  synovial  membrane  extends  further 
upwards  than  on  the  extensor.  The  capsular  ligament  is  moreover  con- 
siderably strengthened  by  the  tendinous  expansions  formed  by  the  lateral 
ligaments,  and  which  prevent  too  g^eat  an  amount  of  extension  of  the 
finger.  Immediately  beneath  the  skin,  and  separated  from  it  merely  by 
bursal  tissue,  are  the  flexor  tendons  of  the  finger,  of  which  the  more 
superficial  disappears  at  the  first  phalanx,  and  the  tendon  of  the  deep  is 
shown  passing  on  to  its  insertion  into  the  ungual.  These  tendons  are 
easily  followed  upwards,  beneath  the  annular  ligament  to  their  muscles 
which  form  the  chief  bulk  of  the  forearm. 


182  PLATE  XXVI 

The  number  of  sections  which  could  be  made  with  advantage  of  the 
hand  is  unlimited,  as  in  every  change  of  position  new  and  interesting 
forms  arise.  This  is  more  particularly  the  case  with  regard  to  the  region 
of  the  thumb,  where  section  is  especially  suitable  for  the  purpose  of 
demonstrating  the  peculiar  relations  of  the  joint  in  dislocation.  It  is  a 
pity  that  no  more  space  can  be  afforded,  and  I  must  therefore  refer  the 
reader  to  PirogofFs  Atlas,  fasc.  iv  B,  tab.  v  and  vi,  where  frontal  sections 
of  the  hand  are  shown,  and  to  fasc.  iv  A,  tab.  iv  and  v,  which  represents 
longitudinal  sections  of  the  thumb  both  in  its  normal  and  dislocated 
conditions. 


\ 


PLATE    XXVII 

THE  series  of  transverse  sections  from  which  the  present  and  following 
plates  were  taken  was  made  from  the  left  arm  of  a  man  set.  40.  The 
arteries  were  injected.  The  forearm  was  slightly  flexed  and  pronated.  In 
order  to  obtain  bearing  points  for  the  individual  laminae,  a  line  was  pre- 
viously drawn  passing  through  the  middle  of  the  biceps  over  the  surface  of 
the  supinator  longus  to  the  thumb,  and  the  uppermost  points  of  each 
subsequent  lamina  lie  in  this  line. 

Fig.  1.  In  this  instance  the  line  of  section  passes  through  the  middle  of 
the  arm,  and  its  surface  is  seen  from  above  downwards,  hence  we  may  imagine 
that  we  have  the  stump  of  an  amputation  of  the  right  arm  for  examination,  as 
has  been  before  suggested  in  speaking  of  the  lower  extremity.  The  section 
is  taken  below  the  insertion  of  the  deltoid,  the  biceps  and  triceps  occupying 
the  greater  space.  On  the  anterior  aspect  of  the  bone  are  portions  of  the 
brachialis  anticus  and  coraco-brachialis ;  in  the  middle,  to  the  right  of  the 
observer,  and  between  the  flexor  and  extensor  muscles,  are  the  great  vessels 
and  nerves,  and  the  musculo-spiral  nerve  has  already  commenced  its  tor- 
tuous course  accompanied  by  the  superior  profunda  artery.  This  position 
of  the  nerve  accounts  for  the  fact  that  blows  or  injuries  from  behind  are 
capable  of  compressing  it  so  directly  upon  the  humerus  that  paralysis  may 
be  the  result.  The  separation  of  the  muscular  masses  of  the  flexors  and 
extensors  is  already  at  this  level  so  decided,  that  the  intermuscular  aponeu- 
rosis  appears  in  the  frontal  plane.  The  relation  of  the  individual  muscles 
is  so  clear  as  hardly  to  demand  any  particular  explanation. 

Fig.  2  is  a  section  of  the  left  arm  in  the  middle  of  its  lower  third. 
The  flexor  and  extensor  muscles  lie  on  both  sides  of  the  humerus,  and 
the  intermuscular  aponeuroses  are  here  still  more  clearly  seen  than  in  the 
preceding  section.  In  the  external  intermuscular  septum  is  the  rnusculo- 


184  PLATE   XXYII 

spiral  nerve,  which  has  nearly  terminated  its  half  turn  round  the  humerus, 
and  behind  it  is  the  origin  of  the  supinator  longus.  On  the  inner  side  the 
ulnar  nerve  has  already  become  distinct  from  the  great  vessels  and  mass  of 
nerves.  The  brachial  artery  is  on  the  inner  border  of  the  biceps,  accom- 
panied by  its  venae  comites,  with  the  median  nerve  above  it.  Although  its 
position  is  here  very  easily  made  out  and  its  compression  readily  performed, 
there  is  great  difficulty  in  isolating  it  and  tying  it  unless  the  steps  of  the 
operation  be  carried  out  very  correctly.  The  vessel,  as  the  plate  shows, 
cannot  be  directly  cut  down  upon,  as  on  account  of  nerves  and  veins  which 
here  often  very  freely  anastomose,  the  operator  may  be  much  embar- 
rassed ;  and  experience  has  shown  that  the  vessel  may  be  easily  missed ; 
the  surgeon  must  therefore  make  for  the  edge  of  the  biceps,  which  is 
slightly  in  front  of  it,  and  open  its  sheath  from  the  inner  side,  when  he  will 
come  directly  upon  it. 

The  distance  of  the  artery  from  the  bone  depends  on  the  development  of 
the  brachialis  anticus.  In  this  instance,  on  account  of  the  muscles  in 
relation  with  it  having  become  more  developed,  the  vessel  lies  further  from 
the  bone  than  in  the  preceding  section.  Compare  fig.  1  of  this  Plate,  and 
also  Plates  X  and  XI,  fig.  3. 

Pig.  3.  In  this  instance  the  plane  of  section  passes  through  the  lower 
end  of  the  humerus  and  the  olecranon.  On  the  left  side  is  the  commence- 
ment of  the  capitellum  with  the  end  of  the  lateral  epicondyle,  on  the  left 
the  trochlea  with  the  middle  epicondyle.  The  olecranon  lies  behind  in  the 
posterior  supra-trochlear  fossa.  The  extent  of  the  cavity  of  the  synovial 
membrane  and  capsule  is  indicated  by  a  dark  line. 

Behind  the  olecranon  is  a  large  bursa  between  the  skin  and  the  tendon 
of  the  triceps.  On  the  right,  in  the  furrow  between  the  olecranon  and 
medial  epicondyle  is  the  ulnar  nerve.  To  the  left  of  the  olecranon  is  the 
anconeus.  The  muscles  of  the  arm  are  much  reduced  in  bulk  at  their  point 
of  attachment.  The  origins,  however,  of  the  flexors  and  extensors  of  the 
hand  and  fingers,  the  pronator  teres,  and  the  supinator  longus,  the  latter,  on 
account  of  its  high  origin  from  the  humerus,  are  more  powerfully  developed 
in  the  section.  On  the  anterior  aspect  of  the  bones  are  masses  of  muscle, 
on  the  posterior  merely  ligaments  and  tendons,  which  allow  of  the  bony 


PLATE   XXVII  185 

prominences  being  clearly  distinguished.  This  relation  of  the  muscular 
masses,  and  the  position  of  the  vessel  on  the  belly  of  the  brachialis  anticus, 
demonstrates  the  fact  that  all  incisions  which  are  intended  to  penetrate  the 
joint  should  be  arranged  on  its  exterior  aspect,  as  it  can  be  here  entered 
without  fear  of  any  considerable  haemorrhage,  and  the  ulnar  nerve  alone 
requires  care  in  looking  after. 

Fig.  4  is  a  section  of  the  forearm  through  the  head  of  the  radius,  which 
is  clearly  shown  with  the  annular  ligament,  and  the  upper  extremity  of  the 
ulna  the  lesser  sigmoid  notch  of  which  lies  in  articulation  with  the  radius. 
The  brachialis  anticus  is  now  for  the  most  part  tendinous,  and  attached  to 
the  ulna  on  the  other  side  of  its  tuberosity.  The  tendon  of  the  biceps  is 
behind  the  tuberosity,  which  lies  below  the  surface  of  the  section,  and  the 
bursa,  between  it  and  the  upper  part  of  this  tuberosity,  is  indicated  by  a 
black  line.  The  brachial  artery  lies  in  the  middle  in  front  of  the  joint, 
enclosed  by  the  origin  of  the  flexors  and  extensors.  Its  division  into  radial 
and  ulnar  is  evident.  In  front  of  it  is  the  communication  between  the 
superficial  and  deep  veins,  and  shows  why  bleeding  in  this  region  is  so 
copious,  if  contraction  of  the  muscles  around  the  deep  vein  be  induced ;  it 
is,  however,  not  possible  to  expose  the  intimate  relations  clearly  by  section. 
It  may,  however,  be  here  explained  that  the  "system"  of  the  median  vein 
does  not  only  associate  the  trunks  of  the  cephalic  and  basilic  with  each 
other,  but  also  keeps  up  a  communication  with  the  deep  veins  accompanying 
the  radial  and  ulnar  arteries.  The  irregularly  formed  and  generally  small 
vein  which  lies  in  the  bend  of  the  elbow  requires  no  particular  note, 
as  it  possesses  no  further  importance  than  the  trunks  which  frequently 
approach  close  to  the  basilic  and  cephalic  in  the  bend  of  the  forearm.  It  is, 
however,  worth  while  to  designate  this  communication,  which  passes  deep 
down,  as  median  (it  is  named  by  Arnold,  the  deep  median  vein),  and  to 
denominate  the  oblique  branches  of  communication  between  the  basilic  and 
cephalic  as  median  basilic  and  median  cephalic. 

The  mass  of  the  flexor  muscles  is  already  at  this  level  more  strongly 
developed  than  in  the  preceding  section.  They  predominate  over  the 
extensors,  as  will  be  still  more  clearly  seen  in  the  deeper  section  of  the 
forearm. 

•       24 


PLATE    XXVIII 

FIG.  1.  The  section  here  passes  through  the  upper  third  of  the  left 
forearm,  and  the  ulna  and  radius  exhibit  surfaces  of  almost  equal  size, 
only  the  ulna  with  its  sharp  edge  lies  closer  to  the  surface  than  the  radius, 
which  is  embedded  in  muscle.  The  ulna  can  be  readily  felt  throughout  the 
entire  length  of  the  forearm,  but  the  head  and  inferior  extremity  only  of  the 
radius.  The  edge  of  the  ulna  affords  an  easily  distinguishable  limit 
between  the  flexor  and  extensor  muscles.  The  flexor  carpi  radialis  forms 
the  muscular  limit  on  the  flexor  surface.  It  is  placed  with  its  tendinous 
border  on  the  ulna,  and  covers  over  the  deep  flexor  lying  beneath  it.  On 
the  opposite  side  of  the  ulna  is  the  origin  of  the  interosseous  ligament,  and 
in  connection  therewith  fasciae,  which  pass  directly  upwards,  and  conse- 
quently separate  both  groups  of  muscles.  To  the  left  lie  the  supinators  and 
extensors,  and  to  the  right  the  pronator  teres  and  flexors.  Between  both 
groups  of  muscles  are  seen  the  vessels,  the  ulnar  artery  deep  down,  with  the 
interosseous  springing  from  it,  and  above  it  the  radial.  One  needs  merely 
to  divide  the  enveloping  fasciae,  and  to  pull  the  muscle  to  one  side  to  expose 
the ,  radial  artery.  The  deep  position  of  the  ulnar  at  this  spot  renders  its 
ligature  difficult.  Of  nerves  the  superficial  branch  of  the  radial  is  found 
below  the  supinator  longus,  the  deep  branch  lying  in  the  supinator  brevis. 
The  median  is  between  the  pronator  teres  and  flexor  sublimis  digitorum, 
the  ulnar  between  the  latter  and  flexor  carpi  ulnaris. 

Peculiar  interest  is  attached  to  the  supinator  brevis,  the  function  of 
which  can  be  readily  understood  by  reference  to  this  section.  Passing  out- 
wards from  the  ulna  (its  upper  set  of  fibres  from  the  epicondyle  are  not 
seen),  it  wraps  round  the  radius  so  that  it  must  by  its  contraction  roll  it 
outwards.  The  space  between  it  and  the  radius  is  taken  up  by  the  tendon 
of  the  biceps,  which  from  the  nature  of  its  attachment  assists  in  supination. 


'/        V    \-   «  &  f   V  1    *      4 

v    \  t  •  *  *  1  i- 1    .,*• 


PLATE   XXVIII  187 

Fig.  2.  In  this  plate,  which,  shows  a  section  through  the  middle  of  the 
left  forearm,  there  is  considerably  greater  difficulty  in  recognising  the 
relations  of  the  individual  structures  than  in  the  preceding,  and  this  diffi- 
culty is  not  so  much  from  the  number  of  muscles,  but  from  the  absence  of 
the  fascial  septa  which  limit  the  individual  groups.  The  interosseous 
ligament  alone  forms  with  the  skeleton  an  absolute  limit,  and  this  does  not 
extend  throughout  the  entire  breadth  of  the  section.  The  ulna  and  radius 
present  their  sharp  edges  to  each  other,  and  are  bound  together  by  the 
interosseous  ligament ;  on  the  right  is  the  mass  of  the  flexors,  and  on  the 
left  that  of  the  extensors.  Both  groups  of  muscles  are  separated  from  the 
radius  by  a  very  thin  fascial  covering,  which  is  attached  to  the  radius 
and  it  encloses  the  radial  artery  and  veins.  This  vessel  is  at  this  level 
easily  found  beneath  the  inner  border  of  the  supinator  longus.  The  ulnar 
artery  and  nerves  are  here  nearer  the  surface  than  in  the  preceding  section, 
and  the  surgeon  has  only  to  make  an  incision  between  the  flexor  carpi 
ulnaris  and  the  flexor  sublimis  digitorum  to  reach  it.  The  fascial  lamina 
passing  from  it  to  the  median  nerve,  and  which  is  prolonged  beneath  the 
origin  of  the  pronator  teres  to  the  radius,  divides  the  deep  layer  consisting 
of  the  flexor  profundus  digitorum  and  flexor  longus  pollicis  from  the  super- 
ficial flexors,  in  which  the  flexor  sublimis  digitorum  has  penetrated  beneath 
the  palmaris  longus  which  has  already  become  tendinous.  In  like  manner, 
on  the  opposite  side  of  the  interosseous  ligament  the  extensors  are  divided 
into  a  superficial  and  deep  layer ;  and  the  extensor  ossis  metacarpi  pollicis 
and  the  extensor  secundi  internodii  are  already  shown. 

If  the  flexor  surface  be  compared  with  the  extensor  with  reference  to 
the  mass  of  its  muscles,  it  is  seen  at  once  that  the  flexor  considerably  pre- 
dominates over  the  extensor,  and  farther  that  the  main  trunks  of  the  vessels 
lie  on  the  flexor  surface.  If  the  surgeon  has  a  choice  of  flap  in  amputation 
of  the  forearm  in  this  region,  provided  there  is  nothing  to  the  contrary, 
he  should  form  his  flap  chiefly  from  the  flexor  surface,  as  much  on  account 
of  the  quantity  of  soft  parts  as  for  the  nourishment  afforded  the  stump  by 
the  vessels.  The  formation  of  flaps  from  the  extensor  aspect  is  much  more 
difficult  of  performance  on  account  of  the  closeness  of  the  bones  to 
the  surface. 


188  PLATE   XXVIII 

Fig.  3  is  a  section  of  the  left  forearm  in  its  lower  third.  The  radius 
has  become  considerably  thicker  in  section.  Its  surface  is  covered  by 
the  broad  pronator  quadratus,  which  from  its  attachment  to  the  ulna, 
rolls  the  radius  over  to  the  position  of  pronation.  Beneath  it  is  the 
interosseous  ligament,  and  on  both  sides  of  it  the  interosseous  vessels. 
The  proximity  of  the  radio-carpal  joint  is  evident  from  the  presence 
of  the  tendons  of  the  muscles.  The  flexors  and  extensors  even  to 
the  flexor  carpi  ulnaris  have  become  tendinous,  consequently  the  radial 
artery  lies  free,  covered  only  by  skin  and  fascia,  hence  affording  the 
readiest  means  of  feeling  the  pulse,  and  is  here  very  easily  ligatured. 
The  ulnar  artery,  on  the  contrary,  is  still  covered  over  by  the  tendinous 
border  of  the  flexor  carpi  ulnaris,  which  must  be  drawn  aside  in  order  to 
reach  it.  On  the  extensor  aspect  are  the  long  muscles  of  the  thumb,  and 
passing  upwards  from  below  the  radial  extensors  of  the  carpus.  At  their 
points  of  crossing,  bursae  are  developed  to  prevent  their  rubbing  against 
one  another.  Over-use  of  these  muscles,  such  as  with  mowers,  may  cause 
inflammation  of  these  bursae  and  form  a  tumour  over  this  locality  (teno- 
synovitis).  The  number  of  muscles  again  on  the  flexor  surface  exceeds 
that  of  the  extensor  surface  in  this  section.  The  mass  of  the  muscles 
has,  however,  so  much  diminished  that  in  amputation  of  the  forearm  in 
this  region  the  flap  a  la  manchette  is  preferable,  as  the  plate  sufficiently 
explains. 

Fig.  4.  In  this  plate  the  section  passes  through  the  carpus.  The 
tendons  only  of  the  muscles  are  now  shown  with  their  bursal  tissue,  the 
presence  of  which  is  indicated  by  the  numerous  black  lines  around  the 
divided  tendons,  the  only  muscular  tissue  cut  being  that  of  the  ball  of  the 
little  finger.  Only  a  small  portion  of  the  radius,  the  root  of  its  styloid 
process,  is  shown. 

The  bones  of  the  carpus  seen,  are  the  semilunar,  scaphoid,  and 
cuneiform,  and  the  articulation  between  it  and  the  pisiform,  the  surface  of 
which  is  seen  anteriorly,  has  been  opened. 

The  three  bones  of  the  first  row  represent  a  surface,  the  individual 
portions  of  which  are  moveable,  and  which  articulates  with  the  radius, 
and  with  the  ulna  by  means  of  the  inter-articular  fibro-cartilage.  The 


PLATE   XXVIII  189 

section  of  these  three  bones,  as  here  represented,  has  not  the  form  of 
an  ellipse,  but  resembles  a  parallelogram,  with  its  angles  rounded  off. 
The  articular  surfaces  of  these  bones  approximate  to  the  spherical  form, 
being  received  into  an  oval  hollow,  somewhat  in  the  same  manner  as  the 
head  of  the  humerus  into  the  glenoid  cavity  of  the  scapula. 


PLATES  XXIX  (A,  B)  AND  XXX 

THE  body  from  which  this  preparation  was  made  was  quite  recent, 
twenty-five  years  of  age,  in  the  last  month  of  pregnancy,  and  received 
in  the  condition  of  rigor  mortis.  Beyond  the  constriction  of  the  neck 
produced  by  the  means  of  death  (hanging)  no  abnormality  existed.  The 
condition  of  the  genitals  corresponded  with  an  advanced  stage  of  preg- 
nancy, and  were  injected  and  succulent.  The  method  of  preparation 
was  carried  out  in  the  usual  manner.  The  foetus,  which  was  divided 
in  the  section  of  the  body,  was  subsequently  restored  to  its  original 
condition,  so  as  to  afford  a  representation  of  its  former  position  in  the 
uterus.  I  chiselled  out  the  foetus  and  the  liquor  amnii  from  the  left 
side  of  the  body,  and  moistened  the  surface  of  the  section  of  the  uterus, 
and  then  froze  it  on  the  right  side.  The  portion  now  lying  in  the  right 
half  of  the  uterus  remained  then  for  the  purposes  of  representation  as 
an  untouched  foetus.  The  left  half  of  the  uterus  and  its  appendages, 
after  the  removal  of  the  rest  of  the  liquor  amnii,  was  represented  as 
empty.  The  foetus,  which  was  in  the  second  position  of  the  head,  was  a 
well-formed  female.  The  vulva  were  closed  and  the  nails  well  developed. 
Its  entire  length  was  about  twenty-three  inches,  its  weight  without 
the  cord  about  six  pounds.  The  cord  was  divided,  and  passed  to  the 
placenta  between  the  head  and  right  arm,  the  placenta  being  placed 
downwards  and  on  the  right  side  of  the  uterus.  The  child,  as  the  plate 
shows,  lay  mostly  in  the  right  half  of  the  uterus.  In  the  section  more 
than  the  right  half  of  the  head  which  was  sawn  obliquely,  was  removed. 
Moreover,  the  left  arm  and  a  portion  of  the  right  shoulder  were  divided 
longitudinally,  and  the  forearm  being  placed  at  right  angles  with  it, 
transversely,  as  well  as  a  portion  of  the  right  leg,  which  extended  towards 


Tab. XXIX  A. 


Tab. XXIX  B. 


Tab.  XXX. 


PLATES   XXIX  AND  XXX  191 

the  left  side.  The  left  knee  was  moreover  grazed  by  the  saw.  The 
back  and  belly  lay  in  the  right  half  of  the  uterus,  and  the  greater  portion 
of  the  liquor  amnii  remained  in  the  left.  As  the  relations  of  this  oblique 
section  of  the  foetus  offer  points  of  no  peculiar  interest,  I  have  refrained 
from  reproducing  the  corresponding  plate  of  the  large  atlas  in  this  small 
edition. 

The  uterus  is  so  folded  over  the  symphysis  that  its  anterior  wall  forms 
a  kind  of  sac,  indicating  a  condition  of  relaxation.  The  numerous  large 
veins  in  its  tissue  are  shown  in  the  plate  in  the  wall  as  simple  strokes, 
their  lumina  becoming  recognisable  only  when  their  walls  were  separated 
from  each  other;  they  appear  patent,  however,  in  the  vaginal  portion 
of  the  uterus  and  in  the  vagina  itself.  The  vaginal  portion  of  the 
uterus  is  proportionately  deep,  and  for  the  most  part  lies  in  the  left  half 
of  the  body,  the  section  having  passed  through  its  right  half  and  opened 
merely  the  first  portion  of  the  cervix,  as  shown  in  Plate  XXIX  u.  It  was 
filled  with  viscid  mucus  and  opened  into  the  cavity  of  the  uterus,  about 
one  fifth  of  an  inch  below  the  plane  of  section,  so  that  its  upper  half  could 
not  be  seen.  The  length  of  the  vagina  at  this  period  of  pregnancy  makes 
it  probable  that  the  woman  was  not  a  primipara,  notwithstanding  that 
there  were  no  cicatrices  on  the  abdominal  parietes,  and  the  os  internum 
was  so  narrow  that  only  a  very  small  sound  could  pass  it.  The  number 
of  veins  met  with  in  the  right  half  of  the  vagina  and  their  swollen  condition 
is  remarkable,  and  their  lumina  are  peculiarly  well  seen  in  the  left  half  of 
the  preparation,  Plate  XXIX  B.  The  falling  in  of  the  vaginal  portion 
of  the  uterus  is  remarkable,  considering  the  empty  contracted  condition 
of  the  bladder.  The  latter  has  slipped  down  bodily  from  the  inner  surface 
of  the  symphysis,  and  is  so  completely  displaced  that  the  course  of  the 
urethra  has  become  bent  at  an  angle.  The  external  os  lies  in  the  hollow 
of  the  under  border  of  the  symphysis,  although,  according  to  Moreau,  it 
corresponds  at  the  end  of  pregnancy  with  the  level  of  the  upper  border  of 
the  symphysis,  and  is  still  higher  according  to  Schultze. 

The  level  of  the  fundus  corresponds  nearly  with  the  under  border  of 
the  first  lumbar  vertebra;  a  more  accurate  definition  cannot  be  given,  as 
the  highest  point  of  the  uterus  was  not  included  in  the  section,  as  it 


192  PLATES   XXIX  AND  XXX 

inclined  more  to  the  right  side.  This  is  almost  the  level  given  by  Moreau, 
and  according  to  the  measurements  of  Schultze  ('  Wandtafeln,'  taf.  vi), 
it  would  appear  to  be  the  second  lumbar  vertebra.  As  the  parts  in  the 
meanwhile  began  to  thaw,  a  more  accurate  measurement  in  this  particular 
could  not  be  made. 

The  depth  of  the  cavity  of  the  uterus  and  its  connections,  and  of  the 
entire  cavity  of  the  abdomen,  is  less  than  is  usually  admitted.  Notwith- 
standing the  size  of  the  foetus  it  is  not  improbable  that  the  attitude  of  the 
body  had  some  influence  in  this  respect,  and  that  lying  horizontally  on  the 
back  the  uterus  obtained  a  kind  of  fulcrum  on  the  vertebral  column,  whilst 
in  the  upright  position  the  yielding  walls  of  the  abdomen  are  pushed  for- 
wards. It  is  farther  to  be  remembered  that  in  dead  bodies  generally  in 
consequence  of  the  high  position  of  the  diaphragm,  the  depth  of  the  cavity 
of  the  abdomen  is  less  than  during  life. 

In  the  present  instance  the  distance  of  the  lumbar  vertebrae  from 
the  anterior  wall  of  the  abdomen  was  almost  one  third  of  the  entire 
sagittal  diameter  of  the  body  at  its  point  of  greatest  distension ;  whilst 
in  the  body  which  in  Plate  II  is  represented  in  the  second  month  of 
pregnancy,  the  lumbar  spine  projects  slightly  beyond  the  middle  of  this 
diameter. 

Finally,  the  vessels  were  in  this  case  uninjected — a  circumstance  which 
is  to  be  taken  into  consideration  in  estimating  the  thickness  of  the  walls  of 
the  uterus. 

The  cavity  of  the  abdomen  extended  tolerably  far  up  in  comparison  with 
its  slight  depth.  The  highest  point  of  the  diaphragm  reached  the  level  of 
the  seventh  dorsal  vertebra,  whilst  in  males,  and  unimpregnated  females 
of  middle  age  it  would  extend  only  as  far  as  the  ninth  or  tenth. 

The  mass  of  the  intestines  was  pushed  downwards,  and  chiefly  lodged 
in  the  left  upper  half  of  the  abdominal  cavity.  The  pyloric  extremity 
of  the  stomach  was  bent  at  an  acute  angle  backwards  and  to  the  left 
side,  so  that  it  was  twice  cut  through.  The  upper  horizontal  portion 
of  the  duodenum  was  directed  backwards.  On  the  left  half  of  the  body 
the  duodenum  is  contracted  against  the  pylorus,  and  moreover  shows  the 
opening  of  the  pancreatic  and  choledic  ducts.  Below  the  duodenum  is 


PLATES   XXIX  AND  XXX  193 

the  pancreas.     The  liver  and  spleen  are  not  enlarged.     The  latter  measured 
5'5  inches  long,  3'8  inches  broad,  and  2  inches  thick. 

The  duodenum  and  pyloric  portion  of  the  stomach  had  pushed  the 
fundus  uteri,  which  lay  more  to  the  right,  together  with  the  rest  of  the 
intestines  over  to  the  left  side. 

The  rectum,  which  was  tolerably  distended,  bent  round  to  its  iliac 
flexure,  towards  the  right  side  whilst  yet  in  the  pelvic  cavity,  so  that  this 
flexure  is  met  with  in  the  course  of  the  section.  Between  the  rectum — the 
folds  of  which  on  the  right  side  are  so  disposed  that  they  might  be  taken 
for  the  valves  of  Kerkring  in  the  plate — and  the  uterus,  is  a  coil  of  small 
intestine,  the  lowest  portion  of  the  ileum  passing  to  the  ascending  colon, 
a  disposition  which  does  not  usually  happen  with  the  impregnated  uterus, 
but  only  in  anteversion. 

In  examining  the  limit  of  the  peritoneum  in  the  pelvis,  it  must  not  be 
confounded  with  the  fascia,  represented  rather  too  thick,  which  passes 
down  between  the  uterus,  bladder,  and  rectum.  The  peritoneum  is  applied 
for  only  a  short  extent  to  the  posterior  wall  of  the  vagina,  and  envelopes 
nearly  half  of  the  posterior  wall  of  the  contracted  bladder,  whilst  the  f  ascias, 
which  enclose  a  loose,  lax  cellular  tissue,  pass  forwards  nearly  to  the  internal 
orifice  of  the  urethra,  and  posteriorly  close  to  the  end  of  the  rectum. 

The  thoracic  cavity  appears  shallow,  in  consequence  of  the  high 
position  of  the  diaphragm,  but,  on  the  other  hand,  very  wide  in  the 
antero-posterior  diameter,  as  may  be  seen  by  comparing  this  preparation 
with  the  section  of  the  female  subject  in  Plate  II.  But  on  the  strength  of 
this,  an  enlargement  of  the  base  of  the  thorax  during  pregnancy  is  not 
necessarily  to  be  inferred,  as  measurements  for  comparison  are  wanting 
before  and  after  it.  Although  it  may  appear  plausible  to  explain  the 
unvarying  size  of  the  spirometer  during  pregnancy,  by  the  fact  that 
the  diminution  of  the  thoracic  space  dependent  on  the  rising  of  the 
diaphragm  is  compensated  for  by  the  traction  of  the  abdominal  muscles 
acting  over  the  uterus  like  a  pulley,  the  anatomical  relations  in  this 
respect  are  not  yet  determined.  Gerhard  found,  by  measurements  on 
living  bodies,  that  in  forty-two  females  in  advanced  pregnancy  the  dia- 
phragm was  in  thirty-six  cases  in  a  normal  position,  in  five  it  was  deeper, 

25 


194  PLATES  XXIX  AND  XXX 

and  only  in  one  higher.  Dorn  in  his  measurements  by  means  of  the  cyrto- 
meter  on  living  females  in  advanced  pregnancy  and  in  lying-in  women, 
found  that  in  most  cases  the  bases  of  the  thorax  had  a  greater  breadth 
during  pregnancy  than  after  delivery,  but,  on  the  other  hand,  its  depth  was 
less  from  before  backwards.  When  the  uterus  was  empty  this  relation  was 
reversed,  the  thorax  collapsed  on  both  sides,  the  transverse  diameter 
decreased,  and  the  vertical  diameter  increased  ('  Bericht  iiber  die  Natur- 
forchenversammlung  zu  Griessen,'  1865,  p.  225). 

In  the  cavity  of  the  -thorax,  in  consequence  of  the  scoliosis  of  the  spine, 
the  section  deviated  to  the  right  of  the  middle  line,  so  that  traversing  the 
lumina  of  the  superior  and  inferior  venae  cavae,  the  right  auricle  and  root  of 
lung  are  met  with,  consequently  the  relation  of  the  openings  of  both  veins 
into  the  heart  are  clearly  seen.  The  inferior  vena  cava,  which  receives  the 
hepatic  vein  just  before  its  entrance  into  the  heart,  comes  from  behind  into 
the  right  auricle,  whilst  the  superior  vena  cava  opens  considerably  further 
forwards.  The  axes,  therefore,  of  the  cavaa  form  an  angle,  which,  owing  to 
the  convexity  of  the  septum  auriculorum,  is  rounded  off.  The  eminence, 
behind  which  lies  the  left  auricle,  is  the  tuberculum  Loweri.  On  the  right 
half  of  the  body  is  noticed  the  external  wall  of  the  right  auricle,  whilst  on 
the  left  a  view  is  obtained  of  the  left  ventricle,  in  front  of  the  entrance  to 
which  is  still  a  small  portion  of  the  rudimentary  Eustachian  valve.  This 
valve  limits  the  posterior  portion  of  the  right  auricle,  in  which  is  still  to  be 
seen  the  original  position  of  the  foramen  ovale.  In  the  anterior  portion  of 
the  auricle,  to  which  the  superior  cava  tends,  the  bulbus  aortaa  forms  a 
flattish  protuberance.  The  aorta  itself  is  not  seen  entirely,  a  portion  of  it 
only  being  exposed.  It  rises  in  front  of  the  superior  vena  cava,  and  then 
disappears  below  the  left  innominate  vein. 

The  section  of  the  lung  seen  in  Plate  XXIX  is  that  of  the  right. 

The  soft  parts  of  the  neck  are  considerably  dislocated  towards  the  left 
side,  owing  to  the  hypertrophied  thyroid  body.  The  trachea  lies  so  far 
over  to  the  left  side  that  only  a  small  portion  of  the  thyroid  cartilage  is  met 
with. 

The  brain  was  divided  through  its  right  half,  the  radiation  of  the  fibres 
of  the  right  corpus  callosum  being  thus  shown.  Beneath  it  is  the 


PLATES   XXIX  AND  XXX 


195 


196  PLATES   XXIX  AND  XXX 

descending  cornu  of  the  right  lateral  ventricle  with  the  pes  hippocampi. 
Beneath  the  dura  mater,  in  the  right  half  of  the  preparation,  a  portion  of 
the  Gasserian  ganglion  and  some  fibres  of  the  fifth  nerve  are  seen. 

The  relations  of  the  skeleton,  however,  are  of  the  greatest  import- 
ance. I  had  therefore,  after  all.  the  plates  were  drawn,  the  halves  of  the 
skeleton  macerated,  and  the  parts  as  accurately  as  possible  adjusted  with 
regard  to  each  other,  as  represented  in  the  adjoining  woodcut.  It  pre- 
sents a  slightly  scoliosed  pelvis,  with  a  like  condition  of  the  spine.  It 
shows  moreover  that  the  deviation  of  the  line  of  section  from  the  middle 
line  was  not  so  considerable  as  the  plate  might  suggest.  The  section  passed 
through  the  pelvis,  as  near  as  possible  in  the  middle  line,  externally  and  to 
the  right  of  the  lumbar  vertebrge,  meeting  the  dorsal  at  their  articulation 
with  the* ribs,  and  passing  again  in  the  cervical  region  to  the  middle  of  the 
spinal  column,  and  subsequently  again  to  the  right  in  the  skull. 

Beyond  the  scoliosed  condition  of  the  spine  there  was  nothing  worthy 
of  remark,  except  that  there  were  two  cervical  ribs,  one  complete  on  the 
right  side,  and  a  rudimentary  one  on  the  left  side  of  the  seventh  cervical 
vertebra.  There  were  seven  cervical  vertebrse,  but  only  eleven  dorsal  and 
five  lumbar.  There  was  a  rudimentary  process  from  the  fifth  lumbar  which 
was  attached  to  the  upper  portion  of  the  sacrum.  The  measurements  of 
the  pelvis  in  inches  were  as  follows  : — The  conjugata  vera  3*8  in.  (the 
conjugata  at  the  narrowest  points  being  3*7) ;  the  right  sacro-cotyloid 
2*8  in. ;  the  left  sacro-cotyloid  3'2  in. ;  the  transverse  diameter  5*8  in.  ; 
the  left  oblique  diameter,  5'08  in.,  and  the  right  oblique  diameter  5'6  inches. 
The  sacrum  was  4*5  in.  deep  and  4'8  in.  broad. 

The  question  arises  whether,  in  a  weak  obliquely  contracted  pelvis, 
showing  such  a  variation,  child-birth  be  possible  without  surgical  aid. 


ahXA.YI 


PLATE    XXXI* 

THE  body  from  which  this  plate  was  made,  was  that  of  a  person  thirty- 
five  years  of  age,  who  died  from  drink  at  the  commencement  of  labour.  An 
examination  of  the  genitals  showed  that  the  liquor  amnii  had  not  escaped. 
After  having  been  prepared  in  the  usual  way,  a  section  was  made  in  the 
mesial  plane  from  below  upwards.  The  symphysis  was  not  however 
exactly  divided  at  its  centre,  but  the  deviation  was  so  slight  that  it  need 
not  be  regarded. 

After  the  drawings  were  made  of  the  right  half  of  the  body,  and  com- 
pletely finished,  the  maternal  structures  were  removed,  in  order  to  obtain 
the  other  half  of  the  child  uninjured  and  in  its  original  position. 

The  child  was  a  well-formed  male  of  about  six  pounds  weight  including 
the  cord  which  passed  downwards  under  the  left  leg,  whence  it  was 
bent  upwards  and  lay  over  the  left  ankle  joint,  being  reflected  sharply 
on  to  the  placenta  which  was  attached  to  the  upper  portion  of  the  uterus. 
The  cord  must  have  been  cut  through  on  removing  the  left  half  of  the 
child,  as  I  afterwards  found  its  placental  insertion  in  the  left  half  of  the 
body.  I  had  divided  it  close  to  its  placental  extremity,  and  it  was  so 
firmly  pressed  against  the  child,  that  it  could  be  with  difficulty  removed 
without  inducing  a  change  in  the  position  of  the  left  lower  extremity. 

The  child's  head  as  is  seen  in  the  plate  is  apparently  in  the  second 
position,  and  was  on  the  point  of  being  born  at  the  death  of  the  mother. 
The  natural  rotation  of  the  head  in  the  pelvis  has  commenced,  being 

*  As  this  chapter  refers  almost  entirely  to  the  section  of  the  child,  and  the  corresponding 
plates  are  not  reproduced  in  this  small  edition,  I  have  thought  it  advisable  to  omit  such  portions  of 
it  as  are  not  illustrated  directly  to  the  accompanying  plate,  and  to  advise  the  reader  interested  in  the 
matter  to  consult  Prof.  Braune's  '  Die  Lage  des  Uterus  und  Fretus  am  Ende  der  Schwangerschaft,' 
which  has  been  already  translated  into  English. — TE. 


198  PLATE  XXXI 

turned  more  to  its  right  side  than  its  trunk.  The  shoulders  are  entirely 
in  the  false,  whilst  the  head  has  already  entered  the  true  pelvis.  The  pro- 
pulsive force  must  have  been  considerable,  as  the  fcetal  head  is  large  and 
the  pelvis  not  particularly  wide,  and  the  evidences  of  this  force  are  shown 
from  the  form  of  the  head.  Its  posterior  portion  is  pointed  or  pear- 
shaped,  and  an  examination  showed  there  was  considerable  effusion  of  blood 
on  the  skull. 

Further  it  appears  that  owing  to  the  strong  contractions  of  the  uterus 
upon  the  child  the  joints  nowhere  exhibit  their  rounded  form  with  the 
freely  flexed  position  of  the  extremities,  as  it  is  packed  in  the  smallest  space 
possible. 

The  skin  was  thrown  into  sharp  ridges.  The  nape  of  the  neck 
appeared  as  a  narrow  chink  between  the  deeply  folded  skin  of  the  back 
and  occiput.  The  bulging  out  of  the  head  in  the  region  of  the  left  ear  is 
remarkable,  being  produced  by  the  pressure  exerted  by  the  narrow  pelvis. 
Just  below  it  is  the  section  of  the  symphysis.  A  deep  notch  is  produced 
in  the  left  arm  by  the  internal  os,  which  has  also  left  traces  behind  on  the 
right  forearm  which  passed  down  longitudinally  over  it. 

The  uterus  itself  is  of  especial  interest,  the  relations  of  which  are  well 
seen  after  the  removal  of  the  entire  child,  and  a  particular  plate  of  its 
empty  cavity  seemed  necessary.  The  uterus  held  the  child  firmly,  and 
had  no  folds  in  it,  from  which  a  lax  condition  of  its  walls  might  be 
inferred.  It  was  placed  with  its  long  axis  directed  nearly  vertically 
towards  the  plane  of  the  inlet  of  the  pelvis,  so  that  it  had  the  appear- 
ance of  having  remained  in  a  state  of  contraction  after  death.  The 
internal  os  lay  somewhat  over  the  inlet,  and  is  noticeable  from  the  lumen 
of  a  large  vein  with  a  smaller  one  beside  it,  the  only  veins  which  were 
found  patent  in  the  walls  of  the  uterus,  in  consequence  of  the  blood 
remaining  in  them. 

In  the  empty  cavity  of  the  uterus,  the  internal  os  appeared  as  a  freely 
projecting  semicircle,  an  inch  and  a  half  above  the  symphysis,  and  four 
fifths  of  an  inch  above  the  premontory  of  the  sacrum.  The  external  os, 
which  was  completely  dilated,  appeared  as  a  small  projection.  It  was 
drawn  out  obliquely,  from  the  region  of  the  lower  border  of  the  symphysis 


PLATE   XXXI  199 

towards  the  articulation  between  the  sacrum  and  coccyx,  and  surrounded 
the  protruding  occiput  of  the  foetus.  The  opening  of  the  right  Fallopian 
tube  was  well  seen  in  the  upper  third  of  the  uterus. 

The  depth  of  the  uterine  cavity  from  the  horizontal  plane  of  the  surface 
of  the  section  to  its  lowest  point  was  2' 6  inches,  and  the  distance  of  the 
internal  os  to  the  fundus  6*6  inches.  The  distance  of  the  external  os  from 
the  inner  in  the  axis  of  the  pelvis  was  4' 5  inches.  The  thickness  of  the 
walls  of  the  uterus  varied  considerably  in  different  places. 

The  placenta  lay  in  the  floor  of  the  uterus,  and  chiefly  in  its  left  half, 
therefore  the  origin  of  the  cord  must  have  been  divided  in  the  section. 
Although  the  patency  of  the  rectum  was  here  and  there  retained,  the 
bladder  was  empty  and  contracted.  Behind  the  symphysis  its  walls  had 
become  so  thin  as  to  be  hardly  recognisable.  Above  and  below  the 
symphysis,  where  the  pressure  had  not  been  so  great,  it  was  thicker,  and 
consequently  better  seen.  On  filling  the  bladder  it  became  distended 
upwards,  so  that  the  anterior  walls  of  the  abdomen  must  have  been  lifted 
up  slightly  from  the  uterus. 

The  protrusion  of  the  abdominal  parietes  by  the  uterus  is  here  more 
considerable  than  in  the  preceding  case,  in  which  that  organ  occupies 
a  different  position,  although  not  so  marked  as  would  appear  at  first 
sight.  In  both  the  spine  projects  beyond  a  third  of  the  entire  depth  of 
the  trunk. 

Unfortunately,  during  the  removal  of  the  left  half  of  the  mother  in 
order  to  obtain  the  necessary  view  of  the  child,  the  skeleton  was  destroyed, 
so  that  it  was  impossible  to  restore  it  as  was  done  in  the  previous  case. 

As  the  vertebras  had  no  lateral  deviations  so  the  section  passed  exactly 
in  the  mesial  line.  The  kyphotic  curvature  of  the  thoracic  and  cervical 
portions,  though  marked,  is  of  no  particular  interest  as  regards  the  relations 
here  shown. 

The  relations  of  the  intestines  and  stomach,  the  former  being,  as  in 
the  other  body,  pushed  upwards,  afford  nothing  worthy  of  remark. 
The  liver  and  spleen  were  normal.  The  former  weighed  about  three 
pounds,  and  displayed  a  protuberance  of  its  anterior  wall,  as  in  the  first 
instance,  the  latter  weighed  about  seven  ounces,  and  measured  5'6  inches 


200  PLATE   XXXI 

long,  2*8  inches  broad,  and  1/2  inches  deep,  was  therefore  rather  less  than 
generally  met  with  in  advanced  pregnancy. 

The  depth  of  the  cavity  of  the  abdomen,  measured  from  the  symphysis 
to  the  cupola  of  the  diaphragm,  is  pretty  much  the  same  as  in  the  former 
case,  whilst  there  is  considerable  difference  in  that  of  the  thorax.  I  need 
call  no  particular  attention  in  this  case  to  the  diameter  of  the  base  of  the 
thorax,  which  naturally  exceeds  that  of  the  female  at  the  second  month 
represented  at  Plate  II.  Any  decided  measurement  as  to  the  depth  of  the 
thorax  during  pregnancy  can  only  be  made  on  the  living  body,  when  the 
relations  of  the  chest  cavity  before  and  after  delivery  must  be  determined. 

The  relations  of  the  heart,  trachea,  larynx,  mouth,  and  brain  were 
entirely  normal. 


I'KINIED    BY   J.   E.    ADLAUD,    BARTHOLOMEW    CLOSE,    E.C. 


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